/£o3/ 6 7s - Columbia QBnitier^itp mtljfCttpcfJtogork College of logicians; anb burgeon* library Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/textbookofsurgerOObrew Epithelioma of Lip. Lumiere colored photograph of a patient in the author's service at the Roosevelt Hospital. A TEXT-BOOK OF SURGERY FOR STUDENTS AND PRACTITIONERS BY GEORGE EMERSON BREWER, A.M., M.D. PROFESSOR OF SURGERY AT THE COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK; SURGICAL DIRECTOR OF THE PRESBYTERIAN HOSPITAL; CONSULTING SURGEON TO THE ROOSEVELT HOSPITAL, THE CITY HOSPITAL, THE MUHLENBERG HOSPITAL OF PLAINFIELD, N. J., AND THE PERTH AMBOY CITY HOSPITAL; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, OF THE AMERICAN ASSOCIATION OF GENITO-URINARY SURGEONS, OF THE NEW YORK ACADEMY OF MEDICINE, AND OF THE NEW YORK SURGICAL SOCIETY; MEMBRE DE LA SOCIETE INTERNATIONAL DE CHIRURGJE; MEMBRE DE LA SOCIETE INTERNATIONAL DE UROLOGIE: MEMBRE CORRESPONDENT DE L'ASSOCIATION FRANC AISE d' UROLOGIE ASSISTED BY ADRIAN V. S. LAMBERT, M.D. ASSOCIATE PROFESSOR OF SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY; ATTENDING SURGEON TO THE PRESBYTERIAN HOSPITAL AND BY MEMBERS OF THE SURGICAL TEACHING STAFF OF COLUMBIA UNIVERSITY THIRD AND ENLARGED EDITION, THOROUGHLY REVISED AND REWRITTEN ILLUSTRATED WITH 500 ENGRAVINGS IN THE TEXT AND 23 PLATES IN COLORS AND MONOCHROME LEA & FEBIGER PHILADELPHIA AND NEW YORK 1915 Entered according to the Act of Congress, in the year 1915, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. IV s " COLLABORATORS HUGH AUCHINCLOSS, M.D. SIDNEY R. BURNAP, M.D. WILLIAM A. CLARKE, M.D. JAMES A. CORSCADEN, M.D. WILLIAM DARRACH, M.D. JOHN A. McCREERY, M.D. FRANK S. MATTHEWS, M.D. CHARLES H. PECK, M.D. EUGENE H. POOL, M.D. JAMES I. RUSSELL, M.D. FRANCIS J. SLOANE, M.D. FORDYCE B. St. JOHN, M.D. ALLEN 0. WHIPPLE, M.D. ARMITAGE WHITMAN, M.D. TO ROBERT F. WEIR, M.D., Hon. F.R.C.S. Eng., PROFESSOR OF SURGERY, COLUMBIA UNIVERSITY, ETC., A MASTER OF SURGERY, A SCHOLARLY TEACHER, A SUCCESSFUL PRACTITIONER, MY HONORED CHIEF AND VALUED FRIEND, THIS VOLUME IS AFFECTIONATELY DEDICATED BY THE AUTHOR. PREFACE TO THE THIRD EDITION. The demand for a new edition has been utilized to the fullest extent by subjecting the entire work to a thoroughgoing revision. This has resulted not only in the complete rewriting of every chapter, with consequent enlargement, but also in the addition of many new ones. The book, in a word, is virtually a new one, and it is confidently hoped that it will accomplish its purpose of presenting clearly every phase of modern surgery. To reach this object with the maximum of certainty, the author has availed himself of the help of a number of colleagues on the Surgical Staff of Columbia University. The plan followed, as far as possible, was to have the chapters upon subjects in which notable progress has been made revised and in some instances largely rewritten by members of the teaching staff of the Medical School who had to do directly with the instruction in these subjects. Thus the chapters on Surgical Pathology have been revised by Dr. Clarke ; the chapter on Anesthesia by Dr. Whipple; that on Bone Infection by Dr. Russell; Dr. Pool revised the subjects of shock and allied conditions, heart and peri- cardium, and has entirely rewritten the section on goitre. The author is indebted to Dr. Mathews for rewriting the sections dealing with hare-lip and cleft palate; to Dr. Whitman for revising the chapter on Deformities; to Dr. McCreery for that on the muscles, tendons, and burs?e; to Dr. Sloane for the one on the bladder, urethra, and male genital organs; and to Dr. Burnap for the chapter dealing with hernia. Dr. Darrach revised the subjects of fractures and dislocations, and added much to the modern operative treatment. Dr. Corscaden revised the chapter on Amputations and largely rewrote the chapter on Diseases of the Joints. Dr. Whipple and Dr. St. John have added an important chapter on Postoperative Treatment, and Dr. Auchin- closs, in addition to revising the chapter on the Lymphatic System, has brought the important subject of hand infections and cellulitis up to date. Dr. Peck revised the subjects of appendicitis, peritonitis, and diseases of the large intestine, to make them correspond with his vin PREFACE TO THE THIRD EDITION lectures and clinical teaching. To Dr. Lambert the author is indebted not only for a careful revision of the chapters on Surgical Technic, Injuries and Diseases of the Nerves, Head, Brain, and Spinal Cord, but also for assuming in large part the duties of Editor. The author's personal revisions have been limited to the chapters dealing with the surgery of the face, neck, mouth, pharynx, larynx, pleura, lung, mammary gland, stomach and duodenum, liver and biliary passages, pancreas, spleen, kidney and ureter. Many of the subjects were completely rewritten, and considerable extra space had to be allotted to include the advanced ideas of pathology and treatment which have been developed since the pub- lication of the second edition. Particularly was this the case in dealing with hand infections and cellulitis, with goitre, and with joint diseases. Many new illustrations have been introduced from photographs from the Record Room and Surgical Laboratory of the Presbyterian Hospital, also an increased number of full-page colored plates have been reproduced from a series of Lumiere photographs of clinical conditions. G. E. B. New Yobk, 1915. CONTENTS. CHAPTER I. Infection Considered in its Surgical Relations 17 CHAPTER II. Inflammation 31 CHAPTER III. Acute Infectious Surgical Diseases 38 CHAPTER IV. Chronic Infectious Surgical Diseases 58 CHAPTER V. Tumors 74 CHAPTER VI. Shock and Allied Conditions 101 CHAPTER VII. Surgical Technic 128 CHAPTER VIII. Anesthesia 153 CHAPTER IX. Treatment of Postoperative Conditions 174 CHAPTER X. Injuries and Diseases of the Skin and Subcutaneous Tissues . 189 CHAPTER XI. The Surgery of the Pericardium and Heart 241 x CONTENTS CHAPTER XII. Injuries and Diseases of the Lymphatic System 278 CHAPTER XIII. Injuries and Diseases of the Muscles, Tendons, Fascle and Bunas . 294 CHAPTER XIV. Injuries and Diseases ok the Xerves 303 CHAPTER XV. Injuries and Diseases ok Head and Brain 324 CHAPTER XVI. Injuries and Diseases of the Spine 374 CHAPTER XVII. Injuries and Diseases of the Face and Neck, Oral, Nasal, and Pharyngeal Cavities 387 CHAPTER XVIII. Injuries and Diseases of the Thorax, Pleura, and Lung .... 459 CHAPTER XIX. Malformations and Diseases of the Mammary Gland 483 CHAPTER XX. Injuries of the Abdomen 500 CHAPTER XXI. Diseases of the Abdomen 507 CHAPTER XXII. Diseases and Injuries of the Kidneys and Ureters 600 CHAPTER XXIII. Injuries and Diseases of the Bladder and Urethra G46 CHAPTER XXIV. Injuries and Diseases of the Penis and Scrotum 688 CO NT R NTS xi CHAPTER XXV. Injuries and Diseases of the Testicle, Seminal Vesicle, and Prostate 699 CHAPTER XXVI. Injuries and Diseases of the Rectum and Anus 723 CHAPTER XXVII. Diseases of Bone 741 CHAPTER XXVIIT. Injuries and Diseases of Joints 766 CHAPTER XXIX. Fractures ' 806 CHAPTER XXX. Dislocations 873 CHAPTER XXXI. Hernia 909 CHAPTER XXXII. Amputations 944 CHAPTER XXXIII. Deformities and Their Correction 964 SURGERY. CHAPTER I. INFECTION CONSIDERED IN ITS SURGICAL RELATIONS. INTRODUCTION. Surgery is that branch of the healing art directed toward the remedying of injuries, deformities, and many other morbid conditions by mechanical operations. Such a conception of surgery differentiates it from the art of medicine. So intimately related, however, are the two that it is almost impossible to draw a sharp dividing line between them. Therefore, in the broader sense, surgery may be said to include the subjects of infection, inflammation, injuries, new growths, foreign bodies, malformations, deformities, and the relief of pain, with the various methods of operative and therapeutic procedure which their betterment entails. The phenomena of infection and inflammation, occurring, as they do, more commonly than all others in surgery, being of fundamental importance and far reaching in their relations to other surgical aspects, it is essential that any exposition of the subject of surgery must be preceded by a thorough comprehension of these phenomena. Although the occurrence of inflammation is often aided by the existence of predisposing agencies, the direct or exciting causes are usually to be found under the heads, direct violence and physical irritation, chemical irritants, and microorganisms. Microorganisms are distributed widely in air, soil, and water, but it is among the habitations of man, where the conditions for their growth and development are especially suitable, that they are most numerous. For the most part, they are harmless species; but pathogenic forms may occasionally be found, especially in localities where the discharges of diseased animals have been allowed to collect. Thus, while the conditions here are unfavorable for the growth of most harmful species, it has been shown that certain pathogenic bacteria have their primary habitat in soil; while others are capable, at any' rate during part of their existence, of finding a nidus there. IS INFECTION CONSIDERED IN ITS SURGICAL RELATIONS So far as we know, then, with few exceptions, micro-organisms whose natural habitat is in the soil or water, are not under normal conditions harmful to man, for they are present in greater or less numbers upon the exposed cutaneous or mucous surfaces of the body, sometimes serving useful functions, as do those in the intestines. Experiments by Nuttall and Schottelius show that the healthy animal is born germ-free. At birth, however, it is at once introduced into a world of bacteria that fall upon the skin and gain entrance to the respiratory passages and alimentary canal through air and food. In a short time they may be found in various parts of the body, so that each part ultimately becomes a regular habitat for a number of species. Notwithstanding, however, the occurrence of bacteria in these situations in great numbers, they do not often gain entrance into the body tissues, so that under normal conditions the blood and viscera have been considered germ-free. It has, however, been urged by Adami and Ford that bacteria reach not alone the deeper structures of the intestine under what appear to be normal conditions, but commonly also invade the blood of the portal circulation and the liver and kidneys during life. Whenever bacteria do find their way into the body, the condi- tions are usually so unsuitable for their existence that they are soon destroyed. Against such incursions the body is guarded in various ways. Of the defensive arrangements which normally exist at the various portals of entry, some are partly mechanical by reason of the anatomic structure of the part. Thus the thick cutaneous covering is impenetrable to most bacteria; the same is equally true for the stratified squamous layer of the mouth, esophagus, and vagina. While the cylindric epithelium covering other mucous surfaces is doubtless less efficient, it should be remembered that they are so situated as to be less exposed to injury. There are certain situations, such as the tonsils and lymphatic apparatus of the gut, which are especially liable to bacterial invasion on account of their delicate covering; but there is abundant reason to suppose, as will be seen shortly, that they are endowed with vital protective properties. In addition to these mechanical defences are the antibacterial qualities of the secretions on mucous surfaces. Some of the prop- erties depend on the chemical action of the gastric juice; some partly on the antagonism offered to invaders by the normal flora of the part; while still others depend largely upon the germicidal qualities of the secretion. But notwithstanding these protective factors, bacteria do some- times penetrate the normal body coverings, and this may especially occur whenever these coverings are injured, even if ever so slightly. Having gained entrance to the tissues they may be engulfed by PORTALS OF ENTRY 19 leukocytes or destroyed by tissue fluids. Escaping, they may be arrested in the regional lymph nodes. If bacteria do reach the blood, they again have to contend with the body fluids and leukocytes. It is evident that in health the body is protected abundantly against ordinary bacterial invasion, but there are conditions in which the strongest and healthiest body is unable to offer adequate resistance; obviously, therefore, it is usually when the vital resistance of the body cells has been lowered that virulent bacteria overcome the natural safeguards to infection. PORTALS OF ENTRY. Bacteria may gain entrance to the body tissues in several different ways. According to the portal of entry, differences not only in the susceptibility of the host but also in the lesions and symptoms of the disease will be noted. Many surgically important bacteria may gain entrance through any portal and induce infection in any part of the body, but some are restricted to certain modes of entrance, as in the case of the tetanus bacillus. For the most part, micro- organisms reach the interior of the body from the skin and mucous surfaces. It is very improbable that bacteria present upon the skin can penetrate this tissue when uninjured. It is true, however, that often they appear to reach the interior of the body from what seems to be an uninjured skin surface, but in these cases it is probable that the skin injury has been overlooked by reason of its smallness. It is only very rarely that bacteria directly gain entrance into the general blood current. They ordinarily reach it through the atria, which have been mentioned. External Sources. — The bacteria derived from without the body are those chiefly concerned in the infection of wounds and many other primary surgical infections. They usually gain access to wounds through contact with infected objects. Air infection is relatively unimportant, and here the bacteria usually occur as clumps attached to particles of dust, so that in a perfectly quiet atmosphere, as in a closed room, these particles containing bacteria rapidly settle upon underlying objects. It is a well-known fact that particles including bacteria are not detached from moist surfaces even by strong currents of air. Among those of surgical importance which are conveyed through external objects are Streptococcus pyogenes, Staphylococcus pyogenes aureus, Staphylococcus pyogenes albus, Bacillus coli communis, Bacillus pyocyaneus, Bacillus proteus, Diplococcus lanceolatus, Bacillus anthracis, Bacillus tetani, Bacillus aerogenes capsulatus, Bacillus tuberculosis, Micrococcus gonorrhea, and a host of others. The relation of insects to the spread of infectious agents has recently been emphasized by Nuttall. Considerable evidence has been accumulated in the past few years which clearly indicates 20 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS that insects may not only carry from place to place disease-produc- ing micro-organisms, but they may also be concerned, directly or indirectly, in the inoculation of pathogenic micro-organisms. Interesting experiments made by Schimmelbusch and others studying the rapidity of absorption of bacteria in wounds, show that they are absorbed within a very short time by lymph and bloodvessels from fresh bleeding wounds. Further, it has been shown that as soon as a coagulum has been formed on the surface of a wound the conditions are changed, and particles like bacteria are no longer quickly transported into the blood and lymph circu- lation. The surface of a healthy granulating wound affords great resistance to bacterial invasion, almost as much as an intact exposed surface of the body. Slight injuries, however, such as probing, removing the dressing, and other manipulations which may convert the ganulating wound into a recent wound, favor the absorption of bacteria. Bacteria of the Skin. — Since the skin is exposed to contamination from the dust and other sources, it is evident that there is scarcely any limit to the number of bacterial species which may be found upon cutaneous surfaces. Most of the organisms ordinarily found are such as may be found in the air or upon external objects. They are principally cocci, but there are great variations in different cases as to the kind and numbers. Sometimes one species far outnumbers the rest. Further, the kind and number of bacteria found upon exposed parts of the skin vary considerably, according to the habits and occupation of the individual. Certain organisms which are met with only exceptionally in most persons, are found commonly on the hands of persons who handle or come into proximity with infected cases. For many of the facts relating to the bacteriology of the skin we are indebted to Welch, who not only called attention to the inconstant characters of the bacteria of the skin but also insisted upon the great regularity with which Staphylococcus epidermidis albus may be obtained in cultures taken from the skin, so that this organism may be regarded as a normal inhabitant in this situation. It is also regularly present in the layers of epidermis along hair- shafts deeper than can be reached by any practical means of cutane- ous disinfection. After complete sterilization of cutaneous surfaces, so that scrapings are sterile, the presence of this white coccus can still be demonstrated on sutures passed through the skin and in excised pieces of skin. Staphylococcus epidermidis albus is usually innocuous. It is frequently present in aseptic wounds of the skin without inducing suppuration or any untoward reactions. However, it may be the cause of disturbances characterized especially by elevation of tem- perature and moderate suppuration. It is a common excitant of stitch abscess. Among other bacteria which may be present upon PORTALS OF ENTRY 21 the skin are Streptococcus pyogenes, Staphylococcus pyogenes aureus and albus, Bacillus pyocyaneus, and Bacillus coli communis. Skin contaminated with the soil, which, as is well known, contains in many situations abundant bacilli of tetanus and of malignant edema, is likely to contain these bacteria. This contamination relates especially to the hands and exposed skin. The smegma bacillus may be considered in connection with skin bacteria. This organism is usually present in the smegma and may be found about the perineum. Attention is called to it par- ticularly on account of its resemblance in morphology and tinctorial reactions to the tubercle bacillus. It has been mistaken for Bacillus tuberculosis in the examination of urine and of secretions and exudates from the external genitals and the anus. Although smegma bacilli are found to be present with pathogenic bacteria in lesions about these parts, they do not possess pathogenic activities for man. Many bacteria are attached to the hair, and particles containing bacteria may readily be deposited from the hair upon wounds. They are, for the most part, identical with those found on the skin. Internal Sources. — The way is open for the access of bacteria into mucous membranes; they communicate with the outer world through the external orifices of the body. The relatively favorable conditions here present for bacterial growth are counteracted in large part by various mechanical and chemical influences which prevent the survival of most bacteria which may enter. There are, however, many bacteria which may multiply or persist for a long time, particularly those of the alimentary canal and of the upper respiratory tract. Among this number there are some which may be pathogenic, but which under ordinary circumstances are not harmful. Mouth and Pharynx. — Although the conditions in the mouth and throat are more favorable for the prolonged existence of many bacteria than upon other exposed mucous membranes, very few of the large number which reach those parts persist there. Most of them either pass into the stomach and intestines or are destroyed in the mouth. Present in the mouth and pharynx are saprophytes, also many streptococci, staphylococci, and pneumococci. Certain of these organisms are frequent in dental caries. The following pathogenic bacteria have also been found repeat- edly in the healthy mouth: Streptococcus pyogenes, Staphylococcus pyogenes aureus, Staphylococcus pyogenes albus, Micrococcus tetragenus, Diplococcus lanceolatus, Bacillus pneumoniae of Fried- lander, Bacillus coli communis, Bacillus diphtherise, Bacillus proteus, and others. The mouth and adjacent parts are the most frequent portals of entry of the organism of actinomycosis; it is especially liable to lodge in or near carious teeth. Respiratory Passages. — With inspiration, bacteria on dust reach the upper respiratory tract. Thompson and Hewlet estimate that from fifteen hundred to fourteen thousand bacteria are inspired 22 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS every hour, the great majority of which are arrested in the nasal cavities. Among the pathogenic organisms which have been found in the nasal cavities may be mentioned the common pyogenic cocci, Diplo- coccus lanceolatus, Meningococcus, Bacillus diphtheria*, Bacillus tuberculosis, Bacillus aerogenes capsnlatns, and Friedlander's pneumobacillus. The presence of capsulated bacilli in the nose is of considerable interest, for organisms of this class have been found with especial frequency in cases of ozena. Bacteria may be present in the larynx and bronchi in health, but in small numbers. Usually the healthy lung is considered free. Stomach and Intestines. — Under ordinary conditions of life bacteria make their appearance shortly after birth in all parts of the digestive tract. In many animals Bacillus coli communis, or its near allies, seems to be, as in man, the chief obligatory form. The relative numbers of Bacillus coli communis in different portions of the alimentary canal have been variously estimated. The observations of Gilbert and Dominici and those of dishing and Livingwood indicate that there is a gradual rise in the number from the duodenum to the ileocecal valve, at which situation the maximum is noted. When the large bowel is reached, there is a marked diminution in the number. The main sources of the bacteria of the stomach and intestines are the ingesta and from dust. From these sources great numbers and varieties are introduced into the alimentary canal, but, as is true of exposed mucous surfaces, only a limited number of species are capable of prolonged existence here. The gastric juice may kill many of those which enter the stomach, but there are many which resist its action. Indeed, some can grow in the human stomach. Emphasis has been laid upon the presence of the Boas-Oppler bacillus on account of its supposed diagnostic value in carcinoma of the stomach, but its presence has been shown to depend upon conditions more common in other gastric diseases. The variety of bacteria in the intestines is large; the presence of some is only accidental or transient, while others are there with such frequency as to merit special notice. The colon bacillus has already been referred to. Pyogenic cocci are rarely absent from the intestines, where they may be present in such small numbers as to escape detection, but the great frequency with w r hich they may be found in perforative peritonitis is significant. Bacillus proteus, Bacillus pyocyaneus, Bacillus tetani, Diplococcus lanceo- latus, Bacillus aerogenes capsulatus, and others have also been found. Under normal conditions the intestinal bacteria are found only a short distance in the common bile-duct; but any alteration from the normal, such as mechanical impediment to the outflow of bile, change in the composition of the bile, or other perturbation in the THE BACTERIAL EXCITANT AND HOST 23 physiology <>t' secretion, may be followed by an ascending infect ion of the ducts or gall-bladder. The relation of the origin of many cases of cholecystitis and cholelithiasis to this form of infection by the colon and typhoid bacilli has been firmly established. Genito-urinary Tract. — It has been shown repeatedly that the anterior portion of the healthy male urethra contains bacteria. These are abundant and varied in the fossa naviculars, and diminish rapidly in number and kind toward the posterior part of the urethra. Urethral bacteria are usually present in urine voided after sterilization of the meatus and fossa, even in the urine passed toward the end of micturition. Among the non-pathogenic and pathogenic bacteria found in healthy urethras may be mentioned the smegma bacillus, and Bacillus coli communis. It cannot be said that the question has definitely been settled as to whether the bacteria of cystitis are usually those normally present in the urethra or those directly introduced from the meatus. The bladder urine in health is germ-free. The female urethra contains micro-organisms, and the anatomic- conditions are much more favorable than in the male for their passage into the bladder. The vagina also contains bacteria in varying number and kind. Pathogenic species are found only occasionally. The so-called "vaginal saprophytes" are the bacteria more constantly present and are evidently harmless. The occasional presence of pathogenic organisms is usually transitory; they may, however, persist for a variable time as harmless parasites. The experiments of Schluter and Witte on the effect of acid on certain bacteria, including pyogenic streptococci, and staphylococci, show that the percentage of acid usually present in the vagina may inhibit their growth. Experiments by Kronig and Menge show that bacteria when introduced into the vagina disappear in a relatively short time. Irrigation of the vagina with water or with antiseptics retards the time of their disappearance. The body of the healthy uterus is ordinarily free from micro- organisms. Stroganoff found the bacteria of the vagina extending up to the mucous surface of the cervix, but not penetrating it, and experimentally proved the mucus an unfavorable medium. Powerful as are the normal defences against bacterial invasion, they may, however, be overthrown under conditions very imper- fectly understood. The more important bacteria found in puerperal infections are the streptococcus and staphylococcus, Bacillus coli communis, and Bacillus aerogenes capsulatus (Plate II). THE BACTERIAL EXCITANT AND HOST. Among the micro-organisms gaining entrance into the body there are some which may under suitable conditions induce phe- nomena by which disease is characterized. These are the ones 24 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS which induce infectious diseases, and which we habitually refer to as being pathogenic bacteria. The term "pathogenic" is, however, a relative one — a fact which should be held clearly in mind for the reason that an organism quite harmless to one animal may be capable of inducing disease in another, and for the additional reason that an organism which under ordinary conditions is harmless may, under special conditions, give rise to definite lesions. It is evident from what has been said that infectious disease cannot occur without the presence in the body of living micro- organisms. But, on the other hand, the mere entrance of bacteria into the tissues is not sufficient to constitute infection, for it has been seen that many bacteria are harmless, and that the body possesses important safeguards whereby bacteria are destroyed or their effects neutralized. Whether the micro-organisms possess patho- genic activity or not will depend largely upon the host, and also upon their own variable nature and qualities. This relationship of host and bacterial excitant has been stated so admirably by Prudden that one can do no better than quote the following : "In the study of the infectious diseases it is especially important to bear in mind that the abnormal processes through which the disturbances incited by micro-organisms are manifested are processes of the body cells, and not processes of the micro-organisms. The micro-organisms do, indeed, incite the train of phenomena by which the disease is manifested, and the nature or 'species' of the micro-organism may largely influence the character of the phe- nomena; but the stored-up energy which is released in this manifesta- tion is body-cell energy, and not that of microbic metabolism. The microbes are excitants of disease, but the disease is a performance of the body cells. If these obvious considerations be held in view, it will be convenient in considering certain of the infectious diseases to use the familiar and much-abused term 'specific' as indicative of those phases of abnormal body-cell performance which are apt to occur in characteristic ways in response to special forms of microbic stimulus. Thus the poisonous substances which the tubercle bacillus builds up out of the organic material upon which it feeds are in part such as exert a peculiar influence upon connective-tissue cells, leading to their proliferation and the temporary formation of new tissue — the tubercle. This, together with associated action of the same or other metabolic products of the living bacillus, forms a group of lesions and disturbances which is characteristic of the action of the tubercle bacillus in the body. In this sense tuberculosis is a 'specific' disease. On the other hand, the poisons elaborated by the tubercle bacillus may incite responses on the part of the body cells which are practically identical with those which many other toxic substances, both of bacterial and of other origin, induce — fever, degeneration, etc. These manifestations of the action of the tubercle bacillus upon the living body cells are not 'specific' THE BACTERIAL EXCITANT AND HOST 25 The Bacterial Excitant. — The reaction of the body cells in infection bears a more or less constant relation to the virulence of the infect- ing micro-organism and to the number of bacteria gaining entrance into the tissues. The virulence varies considerably under different conditions, and according as these variations are small or great different phenomena will develop within the body. The character of the processes induced will necessarily vary according to the virulence of the infecting bacterium; and this largely depends upon its environment, which may not only modify the morphologic: character of the organism but also may change its physiologic activities. For example, Bacillus coli communis, as found normally in the intestines, is of very low virulence, and is not capable of inciting pathologic processes; but so soon as its physiologic activities are modified by changes in its environment its virulence is apt to be very much increased. This influence of environment is also well shown by the modifications which may occur in the vital activity of an organism when it finds its habitat in new and unnatural hosts. Bacteria which enter the body associated with their toxic products are much better able to induce infection than when they enter deprived of their products. These toxic substances, by damaging at the outset cells and fluids which protect the body from infection, enable the invader to gain a foothold which it otherwise might not have obtained. A similar effect is probably produced by the hypothetical substances called aggressins by Bail, which occur in inflammatory exudates. As a rule, bacteria lose their virulence with greater or less readiness when cultivated in artificial media. On the other hand, successive passages of a pathogenic organism through highly susceptible animals exalt its virulence. Thus a streptococcus of attenuated virulence may be exalted a hundredfold or more by successive inoculation into rabbits. Differences in the virulence of bacteria often suffice to explain differences in the clinical and morphologic types of disease. It is well known that under some conditions an organism of low virulence will incite rather mild reactions of the body cells; whereas, under other conditions, when the virulence of the same organism is exalted, the effects are more marked both in severity and extent of the lesions. At the same time, with the most virulent organisms the local lesion may be insignificant and the general disturbance extreme. The number of micro-organisms which gain entrance into the body is also a factor which modifies the character and extent of the cellular reactions. Within certain limitations the healthy body may dispose without apparent injury of a certain number of bacteria of given virulence; but when the same organism is introduced in large quantities infection follows. In highly susceptible animals probably so small a number as one or two anthrax bacilli may incite disease. Usually, however, much larger numbers are necessary for 26 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS the development of an infection. The question of dosage is largely one of individual and racial susceptibility on the one hand, and of virulence of the micro-organisms on the other hand. The kind of infection produced by some bacteria varies with the dose. Thus it often happens that the introduction of a very small number will produce only a local infection, whereas larger numbers may induce septicemia. Further, according to the portal of entry, we find variations in the character of the. infectious process. Thus, a given dose of bacteria which when injected into the subcutaneous tissues of an animal may prove quite harmless, may induce, when the same dose is introduced intravenously or into the peritoneal cavity, well-marked abnormal cellular reactions. The study of the influences which other associated organisms may bring into play in the development of infection is an exceedingly interesting one. Mixed infections are common in the human being, especially in suppurating wounds, in which it is usual to find more than one bacterial species. Sometimes the association of one species may be without influence upon the properties of another, or it may enhance or lower the virulence of one or the other. Bacteria exert their influences on each other largely through their chemical products, and it is often possible to bring about modifications of character by exposing one species to the action of the chemical products of another. Such a process is exemplified by the action of the Bacillus lactis on the bacteria of intestinal putrefaction — use of which is made in the treatment of intestinal auto-intoxication. Sometimes concurrent inoculation of two different bacterial species inhibits the influence of one or both. Thus, simultaneous inoculation of Bacillus pyocyaneus and Bacillus anthracis into a susceptible animal is often without pathogenic effect. More often, however, the concurrent inoculation of two species rather increases the danger from one or both, although sometimes a bacterium of attenuated virulence may become augmented in virulence by the inoculation of another species which need not necessarily be pathogenic itself. Thus the pathogenic effects of the tetanus bacillus arc much enhanced when it is associated with pyogenic bacteria. It sometimes happens that infection with one species paves the way for infection with another. The Host. — It is, of course, well known that certain bacteria will induce infections only in separate species of animals, proving absolutely innocuous for other species. Thus, while the anthrax bacillus usually induces lesions with the greatest readiness in many animals, others, like the white rat, are ordinarily insusceptible to inoculation with these bacilli unless very large amounts be given or special factors be brought into play. Furthermore, some diseases are especially peculiar to man, such as typhoid fever, leprosy, scarlet fever, measles, etc., these diseases never occurring naturally in animals. ACTION OF BACTERIA AS I) THEIR PRODUCTS IN THE BODY 27 Racial predisposition may be inherited or acquired, or general or local. Negroes arc generally insusceptible to yellow fever, whereas other human beings are quite susceptible to the pathogenic agents of this disease. The influence of age is so well known that investigators commonly make use of this knowledge in their experimental work. As a predisposing factor to infection this is well illustrated by the curve of frequency of infections diseases in man, the maximum point occurring in children. Numerous other conditions affecting the normal physiologic integrity of the body also favor the development of infectious disease. For example, the influence of fatigue, starva- tion, cold and heat, and loss of blood has been studied particularly from an experimental point of view, the results conclusively proving that a marked susceptibility to infection is developed when any of these factors is brought into play. Other factors have also been investigated, such as the action of chemical substances and unsuitable diet, the latter especially by Hankin, who fed refractory rats on sour milk and bread. Such treatment made the animals extremely susceptible to anthrax infection. The local predisposition may be limited to one or more of the portals of entry, or it may exist at some point within the body, constituting a so-called locus minoris resistentiae. The character of the tissue infected, the presence of local anemia or passive hyper- emia, the withdrawal of nerve impulses from a point, the rapidity of absorption, the presence of foreign bodies, are also modifying factors in the susceptibility to infection. Wounds through poorly vascularized tissues generally offer but slight resistance to bacterial invasion. The presence of edema in the tissue likewise favors infection. Contrary to the general belief, suppurating surfaces offer con- siderable resistance to the entrance of bacteria into the body, for pus possesses distinct bactericidal power, partly from the cells and partly from the fluid portion. Thus the danger of bacterial absorp- tion from suppurating surfaces is much less than from fresh wounds. The existence of suppuration, however, lowers the general resistance of the individual. Among the local conditions favoring the growth, in wounds, of bacteria which might otherwise be disposed of by the tissues or animal fluids, may be mentioned strangulation of masses of tissue by ligature, the presence of foreign bodies, interference with the circulation from undue pressure and tension. ACTION OF BACTERIA AND THEIR PRODUCTS IN THE BODY. Micro-organisms induce their effects in several ways, but chiefly by their presence in the tissues, and by the development of their 28 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS poisonous products, which either .affect the physiologic activity of the cell or kill the cell outright. These poisonous products act in varying degree, generally or locally, according to the nature and quantity of the product formed. Such toxic substances become diffused through the system, and the clinical manifestation of their effects is shown by the occurrence of fever, disturbances in the functions of the respiratory and nervous systems. In some cases changes are found locally in the tissues directly involved. The general effects of bacterial poisons may be so slight as to be regarded as of little importance, as in the case of a local inflammation; or they may be very intense, as in tetanus and diphtheria. In diseases like tetanus and diphtheria it is usually only in the local lesion that the bacilli are found; and the profound systemic intoxication is due to absorption of the highly toxic products from the local lesion. Whenever there is a widespread distribution of pathogenic bacteria in the blood the condition is designated septicemia; and if associated with multiple foci of pus-formation, the term pyemia is applied. The body, which is already the seat of infectious disease, is much more susceptible to invasion by other bacteria; thus, mixed or concurrent infections are often present. Individuals the victims of long-standing chronic diseases, such as those of the heart, lungs, kidneys, and liver, often succumb to infectious diseases of one kind or another. The term terminal infection has been applied by Osier to these infectious diseases. IMMUNITY. Immunity is characterized by resistance to infection or its effects. The absence or loss of this capacity is known as susceptibility. Immunity from an infectious disease may be hereditary or it may be acquired, either by an attack of the disease from which the individual has recovered — natural immunization — or by the intro- duction into the body of something which diminishes susceptibility — artificial immunization. Many of the infectious diseases confer greater or lesser immunity to subsequent attacks of the same disease, although there are excep- tions to this rule. A previous attack of erysipelas renders one more susceptible to subsequent infection with the streptococcus. From the study of infection it is known that two distinct influences are evidently at play in enabling the body to resist infection. It has clearly been shown that the destruction of bacteria may in part be brought about by the leukocytes and other mesodermal cells, which when thus engaged are called phagocytes. In the body fluids there are also certain albuminous ingredients which have well-marked bactericidal properties. A number of theories have been advanced to explain the essential nature of immunity. They may be grouped into two classes: The IMMUNITY 29 humoral, which attributes immunity to extracellular fluids of the body, and the cellular, which assumes that the direct action of the body cells is most important. The humoral products of immunity, which are best known, are antitoxins, lysins, opsonins, precipitins, and agglutinins. Antitoxins result after the introduction into the body of toxins under suitable conditions, and are protective and curative because they unite with toxin of the kind which has called it forth and prevent it from causing disease by union of the body cells with toxin. Lysins result from the introduction into the body of bacteria and other cellular bodies, under suitable conditions, and act by dissolving or destroying the cellular bodies of the type which called forth their production. Opsonins are substances in the serum which result after the introduction into the body of bacteria and some other cellular bodies under suitable conditions, and act by forming a union with these cellular bodies in such a way that they may be more readily engulfed by phagocytic leukocytes. Precipitins are substances in the blood serum which result from the injection into the body of various protein substances of animal, vegetable, or bacterial nature having the power of forming a pre- cipitation when mingled with these substances. This action is more or less specific for the especial form of substance. The same is true of agglutinins, which under similar circumstances are capable of drawing together into clumps bacteria and other cellular bodies which have been introduced into the serum of animals. While precipitins and agglutinins are thought, undoubtedly, to have a place in the protective mechanism of the body, their true role is not yet known. As methods of determining the type of infection which the body is undergoing, however, these phenomena — on account of their specific action — are great diagnostic aids. The one best known at the present time is the agglutination of typhoid bacilli in the presence of the serum of typhoid fever patients, known as the Widal reaction. As a result of these phenomena the following various serothera- peutic measures have been inaugurated to overcome the deleterious effects of bacterial infection. Curative injections by (a) active immunization and (6) passive immunization. (a) Active immunity is secured through the action in the body of bacteria whose virulence has been reduced but not rendered altogether inert. Common examples are bacterial suspensions, recently designated as vaccines, of staphylococci, streptococci, gonococci, colon bacilli, and other organisms. The use of these substances has been encouraged through the 30 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS researches of Wright, who recommends the use of the opsonic index to regulate the size and intervals of their dosage. Bacterial vaccines are prepared from cultures of the organisms causing the infection, grown on agar. A suspension is made of the bacteria in normal salt solution, and this is then standardized by determining the number of bacteria per cubic centimeter of fluid. After sterilization by exposure to a temperature of from 65 ? to 75° C' for half an hour and the addition of 0.5 per cent, lysol, this material is ready for inoculation. Tuberculin — especially Koch's new tuberculin, known as tuber- culin R — is a substance belonging to this class of immunizing agents. Up to the present time this form of immunization has been most successful in cases of localized infection. (6) Passive immunity is secured by the direct mingling of the body fluids from an individual already immunized with those of the individual to be protected. Such fluids are the antitoxic sera — represented by diphtheria and tetanus antitoxin and others — and antibacterial sera, to which group belong the sera of typhoid, cholera, plague, dysentery, etc. These methods may be applied not only for curative purposes but also to prevent the effects of future infections. Protective passive immunization may thus be obtained for comparatively short periods of time by the use of diphtheria and tetanus antitoxins where infection by the corresponding organism is threatened. Of the agencies producing protective active immunization, the most familiar are the vaccine of Jenner, producing immunity to smallpox, and the antirabies vaccine of Pasteur. In both of these cases, as well as in some successful experiments in tuberculosis immunity, immunization is secured through the injection of living attenuated organisms. The use of dead organisms as vaccines for the production of active immunity has recently met with a certain degree of success in protection against infection of typhoid fever, plague, and some of the pyogenic organisms. The protection afforded by active immunization is generally of longer duration than that afforded by passive immunization. It is to Metchnikoff and his pupils that we owe most of the facts upon which the cellular theories of immunity are based. Immunity, it is asserted by those who take this view of immunity, is dependent upon the activity of living cells, the germicidal action of the body fluids being due to secretions from the leukocytes and other cells. (See Phagocytosis, under Inflammation.) It is probable that the body fluids and body cells both play an important role in the development of immunity. CHAPTER II. INFLAMMATION. Introduction. — With a fuller appreciation of the structure and physiologic traits of the tissues, chiefly based on studies in biology and comparative pathology, the original significance given to the process of inflammation has been much changed within recent years. Originally the conception of inflammation was a comparative simple one, based chiefly on certain clinical manifestations — redness, heat, swelling, pain, and impaired function; but now it is regarded as a far more complex local process, in which circulatory disturbances and retrogressive and progressive changes are associated in varying degrees. These changes are induced by some form of injury. While the external manifestations of the process may vary considerably, it has been shown that in each case the fundamental changes are essentially the same whatever the exciting cause. Thus inflamma- tion has been defined by Adami as "the local adaptive changes resulting from actual or referred injury." INFLAMMATION. Cause. — Although the varieties of inflammation are dependent upon the character of the cause, they may be grouped, according to their intensity and duration, into the acute and chronic forms. In either form the active or exciting cause may have been physical, chemical or thermal change. Inasmuch as the bacteria and other microorganisms produce inflammation in their metabolism they do so by chemical changes. While any one of these agencies may, in itself, be sufficient to incite inflammation, in some instances they are only able to produce this result through the operation of some predisposing cause. Acute Inflammation. — Symptoms. — Local. — The cardinal signs of inflammation have long been recognized as heat, redness, swelling, and pain, and to these may be added interference with function in the inflamed part and general constitutional disturbance. While inflammation may exist in the absence of some of these signs, and while some of them may occur with conditions other than inflamma- tion, the coexistence of all, or even of a majority of them, is usually sufficient to establish the diagnosis of inflammation. The redness is due to arterial and especially to venous and capillar}' hyperemia; the swelling, on the other hand, is due partly to hyperemia, serous 32 INFLAMMATION exudation, and leukocytic emigration. The pain is due possibly to increase of tissue tension irritating the nerve ends or possibly to the direct actions of the inflammatory irritants upon the nerve ends. Although the temperature of the involved part may be elevated beyond the normal, it never exceeds that of the interior of the body. Disturbances or loss of function depend on the struct- ural and functional alterations which occur in the tissue affected. General Symptoms. — These may be absent in inflammations of a limited and moderate nature; but when the inflammation is extensive and severe, fever is ordinarily present. It is induced by the absorp- tion of substances from the local area of inflammation. There may be leukocytosis, polymorphonuclear in type, with the inflam- matory processes due to certain bacterial invasions. Such inflamma- tory processes are the result of invasions by the so-called pyogenic organisms. Clinically, all cases with fever are attended with certain symp- toms in common, due partly to increased tissue changes, partly to increased heat of the body, and in part to functional disturbances of certain organs. There may be malaise, sleeplessness, thirst, loss of appetite, mental disturbance, increased frequency of pulse and respiration, lessened amount of urine, etc. If the absorption of poisons is excessive, or a vital organ is involved, death may result, or all symptoms may subside and the process may terminate in resolution, or may continue as a chronic condition. In acute inflammation the character of the minute tissue changes depends upon the vascularity or non-vascularity of the tissues. In non-vascular tissue the process of inflammation is eventually similar to that in vascular tissues. In the non-vascular cornea, tendons, and heart valves, vessels rapidly develop. In this way a non-vascular tissue becomes vascular. With the appearance of the vessels the tissues become permeated with wandering leukocytes. These leukocytes emigrate from the vessels and adjacent tissue zones to the inflammatory focus through so-called positive chemota.ris. This chemotaxis is exerted through tissue debris and particularly pyogenic organisms. Many of the leukocytes may take up micro-organisms, and by the action of intracellular ferments bring about more or less com- plete digestion of the ingested bacteria. This phenomenon is known as phagocytosis. While usually resulting in the destruction of the ingested bacteria, these are not always killed; on the con- trary, under some circumstances the ingested bacteria and their products may destroy the phagocytes. The digestive action of leukocytes on bacteria may not be con- fined to bacteria within their bodies, for after their disintegration ferments may be released and imparted to the exudate or serum which have a bactericidal action. To such substances the term alexins has been applied. INFLAMMATION 33 Tn the earliest stages of inflammation there is arterial dilatation, and at the same time an increase in the rapidity of flow of blood, which is of short duration. This is followed by a dilatation of the veins and capillaries, with a slowing of the blood current. The leukocytes now have a decided tendency to accumulate in the outer portion of the veins and capillaries, and to adhere to the vessel walls. This is followed by emigration of the leukocytes through the vessel walls. The slowing of the blood current is progressive, and in some vessels complete stasis occurs. Red cells Fig. 1. — Mesentery of frog in the early stage of an acute inflammation. All of the vessels are dilated. The leukocytes are more numerous; they have collected along the walls of the vessels, and in several places are passing through; at d diapedesis of the red corpuscles is shown, and at e emigration of leukocytes. There are large numbers of leukocytes in the connective tissue. (Dennis.) may escape into the tissues either by diapedesis or rhexis. Plasma also escapes, the fibrinogen of which coming in contact with the ferments of disintegrating leukocytes, forms fibrin (Figs. 1 and 2). If now the cause of the inflammation ceases to act, and the vitality of the tissues has not been too much lowered to permit of their recov- ery, the stasis ceases, the emigration of leukocytes discontinues, and those that have already escaped wander back into the bloodvessels or lymphatics, or disintegrate — the dead cells being dissolved by cellular ferments — and the part is left apparently uninjured. This is 3 34 INFLAMMATION called resolution. This inflammatory process in the tissues, especially if due to bacterial invasion, clinically is known as a cellulitis. The tissue damage by a suppurative process may be replaced by thickened or indurated tissue, giving rise to a connective-tissue fibrosis — often resulting in cicatrization — or all the tissues in the inflamed area may lose their vitality and die en masse {gangrene). Chronic Inflammation. — While chronic inflammation may be the immediate result of the specific infectious agencies of such diseases as tuberculosis and syphilis, it may result secondarily to an acute process from other causes where the exciting factors continue in operation. - ' -V. ';v^$&v ''*•'&$&*&££ Fig. 2. — Acute inflammation of an appendix, showing dilated lymph vessel and leukocytic migration. The causes of chronic inflammation are similar in kind to those of the acute processes, but act with less intensity and for longer periods of time. The local symptom — redness, pain, and heat — may be very slight or entirely absent. Swelling is frequently a marked sign. The minute tissue changes in the early stages resemble those of the acute form, with greater sluggishness of the blood supply and pro- liferation of the fixed tissue elements. This may result in the collection in the adjacent tissue of numerous small round cells. In other cases, as in syphilis, actinomycosis, or tuberculosis, the local irritation pro- duced by the specific organism gives rise to circumscribed areas of round-cell infiltration, which have a strong tendency toward necrosis, caseation, or calcification. These lesions are spoken of as the infect ire PLATE II Section through wall of abscess, showing Staphylococcus pyogenes, aureus. (Baum- garten.) Cover-glass preparation of pericardial exudate, showing Bacillus pyocyaneus stained blue and the tubercle bacillus stained red. (Ernst.) T MM i •;. « s { Streptococcus pyogenes. Streptococcus erysipelatis. (Prudden.) ft> I ^A Micrococcus gonorrhea or gonoeoecus. (Abbott.) Micrococcus lanceolatus (Abbott.) Some Forms of Bacteria Giving Rise to Surgical Infections. SUPPURATIOX 35 granvlomata. Like acute inflammation, the chronic may terminate in resolution, suppuration, or ulceration; but the fibrous and necrotic changes just described are the terminal results most frequently seen. SUPPURATION. Suppuration is produced by the action on the tissues of the body of certain organisms known as the pyogenic bacteria. While some of these, as the staphylococci, streptococci, the pneumococcal, gono- coccus, Bacillus coli communis and Bacillus pyocyaneus nearly always produce pus, others are capable of producing pus only at times. To this group belong the typhoid, proteus, tubercle, anthrax, and glanders bacilli, and the bacillus of malignant edema. (Plate II.) Pus, caused by these organisms as a class, is a yellowish creamy substance with a faint odor, having an alkaline reaction and a specific- gravity of about 1030. It is composed of a solid and a liquid, the former consisting of leukocytes, some of which may still retain ameboid movements, most of which, however, are undergoing degeneration and disintegration. In addition to these may be found dead tissue cells, red blood corpuscles, fibrin, micro-organisms, etc. The liquid part resembles modified plasma, which does not clot on standing, but which may be coagulated on boiling. Certain variations in the appearance of pus are dependent upon the character of the organisms calling it forth. For example, while the pus in staphylococcus infection is grayish white, moderately thick, with a somewhat sour odor, that of the Bacillus coli communis is thick, brownish, with fetid odor; or thin, grayish white, with thicker masses. Pus from streptococcus infection is usually thin, white, often blood- tinged, with shreds of tissue, while that from the Bacillus pyocyaneus is distinctly green or blue. Pneumococcus pus is usually thin, watery, and greenish, while tubercle bacillus pus is usually thick, curdy, paste-like, or thin and greenish, containing cheesy lumps. A suppurative process may occur in a circumscribed area, forming a local abscess, or it may infiltrate the tissues, forming a diffuse cellulitis. Acute Abscess. — The minute tissue changes, occurring in the early stages of abscess formation, have already been described under inflammation. If the inciting organism remains active, the exuded leukocytes gather about the focus in large number.-, with the other products of inflammation, and as a result of the action of the bacterial poisons, these cells, as well as endothelial and connective-tissue cells, die. Through the action of cellular and bacterial ferments, leukopro- teoses, the tissues are digested into a semifluid mass. This mass or "slough" is frequently found lying free in an abscess cavity; at other 36 INFLAMMATION times the necrotic mass is completely liquefied, resulting in a collection of homogeneous pus. About this central focus is an inflammatory zone of tissue, infil- trated by leukocytes and other products of inflammation, in which the capillaries are dilated. As the process extends the central area of necrosis becomes larger. As the pressure at this point is considerable, the process extends in the direction in which the tissue structure is digested more rapidly by the proteolytic ferments, along the line of least resistance, until it points upon a free surface or in some body cavity. In the course of this advance the pus may burrow for some distance between fascial planes. ./t-~- -**%$&** Fig. 3. — Recent granulation. Duration 48 hours. After the evacuation of pus, bacteria, and other irritants from the abscess cavity, healing may occur. The obliteration of the defect in the tissues left by the abscess cavity is brought about partly through the proliferation of so-called "granulation tissue," and partly by the collapse of the surrounding tissues. Granulation tissue consists of newly formed connective tissue rich in blood capillaries (Figs. 3 and 4). With the tissue defect complete, epithelium from the adjacent skin or mucosa is found to have covered the newly formed connective tissue or "scar." The entire new tissue growth is called the "cicatrix." In the absence of repair at any stage, the infection may travel along the lymphatics supplying the part, to the nearest lymph node, which becomes inflamed and enlarged. The process may stop in the first or second of a chain of nodes, or the infection may pass into the blood, resulting in a septicemia or pyemia, which may prove fatal. These conditions will be described subsequently. SUPPURATION 37 Chronic Abscess. This form of abscess may result from long duration of an abscess, originally acute, the exciting cause of which is an enfeebled pyogenic organism, or one of slight virulence. More frequently, however, a chronic abscess is of slow formation from the start, and due to infection by the inciting organism of tuberculosis, syphilis, actinomycosis, or blastomycosis. The pus from a simple chronic abscess may be thin and curdy, may contain shreds of necrotic tissue, but often differs little from ordinary pus. Locally, a fluctuating swelling is the chief sign, often unattended with any sign of inflammation. Constitutional symptoms are rare. •/"•'". *V*W£Jl' i . ism -^*m s« m <** »• ■ 4*£^3^' * ♦ • .-V • - • t * *».*.»'• .** > . Fig. 4. — Recent granulation tissue. Duration 5 days. The symptoms and treatment of chronic abscess will be considered in subsequent chapters. Sinus. — A sinus is a persistent tract which communicates with an abscess cavity. The cause is usually the presence of a foreign body in the original focus, or an insufficient outlet from an abscess. Fistula. — Although occasionally the result of a wound, ulceration, sloughing, or of a congenital defect, a fistula is usually due to the non-closure of an abscess. A fistula connects some hollow viscus or the duct of a secreting gland with the surface of the body. The fistulse most commonly seen occur in connection with the gastro- intestinal tract, the urethra, or bladder. CHAPTER III. ACUTE INFECTIOUS SURGICAL DISEASES. ACUTE GENERAL SEPSIS. Septicemia, Pyemia, and Septic Intoxication. — Although formerly considered separate diseases, these three conditions are best regarded simply as different types of acute general sepsis. Whenever patho- genic bacteria gain access to, and grow in the systemic circulation and tissues, the condition is referred to as septicemia. If, on the other hand, such generalized infection be associated with the development of remote foci of suppuration, it is designated pyemia. It has been customary, especially among surgeons, to limit these terms to infections with the pyogenic micro-organisms. The term septic intoxication is used to indicate a condition due to the absorption of toxins, mainly of bacterial origin. Sapremia is a term sometimes employed to signify a form of intoxication due to absorption of the poisons of putrefactive micro-organisms. It is not always possible to distinguish sharply between infections and intoxications; indeed, the manifestations of infectious disease are nearly always referable to bacterial poisons. Some infections are purely local, as tetanus and diphtheria, the most important lesions and symptoms being due to absorption of toxic substances from the seat of inoculation. The so-called intoxica- tions exhibit themselves by febrile manifestations, nervous, cardiac, and respiratory disturbances, and other symptoms. The septicemias generally may be traced to the entrance of the bacteria at some definite portal; but sometimes it is impossible to determine the point of entrance — cryptogenetic infections. Many of the organisms gain access to the blood through the skin or mucous membranes of the alimentary, respiratory, and genito-urinary tracts. Such infections may follow recent or old injuries; or they may come on in the course of various diseases, such as pneumonia, erysipelas, typhoid fever, puerperal fever, etc. The organisms most frequently etiologically related to the develop- ment of surgical septicemias are Streptococcus pyogenes, Staphy- lococcus pyogenes aureus, Pneumococcus, Bacillus coli communis, Gonococcus, Bacillus pyocyaneus, Bacillus aerogenes capsulatus, and Bacillus anthracis. More than one bacterial species may be present in the blood. The bacteria concerned in pyemia are essentially the same as those found in septicemia. Why they should in one instance induce foci of suppuration and not in another, it is not always possible ACUTE GENERAL SEPSIS 39 to state. In most cases there is some primary focus of infection, either an osteomyelitis, an otitis media, an external suppurating wound, a gonorrhea, or other lesion containing pathogenic bacteria. Metastatic abscesses usually are formed by fragments of infected thrombi which are carried into the circulation, and eventually are arrested in small vessels and thus form embolic foci of suppuration. The abscesses are generally found in one or more of the viscera, as the kidneys, lungs liver, spleen, or heart. When the focus of infection is within the areas supplied by the portal vein, pylephlebitis often develops, with multiple abscesses in the liver. At autopsy the spleen is found swollen and soft, and on the serous surfaces minute hemorrhages are frequent. The lungs may be con- gested and the other viscera show parenchymatous degeneration. Embolism and thrombosis with infarction are not uncommon. Symptoms. — In all cases of acute general sepsis there are fever, prostration, and rapid wasting. In the intoxications due to an accessible septic focus there is often a chill, followed by high fever, rapid heart action, headache, general malaise, and often restlessness and delirium. Accompanying these there is pain at the seat of infection, with swell- ing, redness, and other evidences of inflammation. If the septic focus is promptly opened and disinfected, the symptoms rapidly subside. In the septicemic type of general sepsis the symptoms are at first similar to those of simple septic intoxication, but are not relieved by the opening and disinfection of the primary focus. On the contrary, there is continued high fever, with great prostration and progressive loss of flesh and strength. Nausea and vomiting, diarrhea, albumin- uria, and symptoms of uremia may appear. Delirium is marked and coma may develop shortly before death. In the pyemic type of the disease the onset is, as a rule, more gradual; and if preceded by symptoms of intoxication from an unrelieved septic focus the first sign of the pyemic process may be the occurrence of a metastatic focus in some remote portion of the body. In the majority of in- stances, however, there are chills, irregular fever with marked daily remissions and profuse sweats. The skin becomes sallow and evi- dences of metastatic abscesses develop in the lungs, liver, brain, kidneys, joints, and on the surface of the body. In all three t}pes of the disease leukocytosis is present, and in the two last ulcerative endocarditis is apt to develop. Prognosis. — In simple intoxications the prognosis is generally favorable if the focus can be found and removed. In the septicemic and pyemic types the prognosis is decidedly unfavorable; the former generally die in from ten to fourteen days; the latter, in from two to eight weeks. Treatment. — The treatment of general sepsis consists in measures to remove the focus of infection, hasten the elimination of the poison, and to increase the natural resistance of the patient. Local measures consist in opening and evacuating the focus of infection, the employ- 40 ACUTE INFECTIOUS SURGICAL DISEASES ment of drainage and asepsis. Removal of an infected bone or organ, or amputation of an extremity may be necessary. Of the bacteriolytic sera, few have given promise of yielding favor- able results. The antigonococcic serum of Torrey, Rogers and Beebe has produced benefit in infections by this organism, which has been most evident in the local manifestations — as arthritis. Antistrepto- coccus serum has been employed for some time with reports of a few favorable results. Failure in the past to derive beneficial results from the use of this serum in all probability arises from the fact that there is a scarcity of complement available at the time of injection to activate the serum employed. This may be overcome by deriving the thera- peutic sera from a species of animal closely allied to man or by in- creasing the amount of complement in the blood of the patient. Abbott, Longcope, and others have already shown that the amount of complement in the blood may be reduced by alcohol and various chronic as well as acute diseases. The use of bacterial vaccines, while productive of beneficial results in some local infections, have given little promise of help in systemic infections. Recently Hiss has reported beneficial results in staphylococcus, streptococcus, pneumococcus, and meningococcus infections from the subcutaneous injection of extracts of leukocytes. The action of these extracts is believed to be due to endo-antitoxins liberated from the disintegrated leukocytes. It is possible that the amount of complement is also thus increased. ERYSIPELAS. Erysipelas is an acute infectious disease, characterized by a spread- ing inflammation of the skin, induced by Streptococcus pyogenes. There is a tendency to spontaneous recovery. The disease is accom- panied by febrile disturbances. Etiology. — The inciting bacterial agent is a streptococcus, as was shown by Fehleisen, in 1884. He obtained pure culture of the organ- ism and named it Streptococcus erysipelas. It is now generally assumed that this organism and Streptococcus pyogenes are the same. Erysipelas is endemic in most countries, and is particularly fre- quent in the spring. Chronic alcoholism, chronic nephritis, and other diseases are predisposing factors. The most frequent point of entrance for the streptococcus is through a wound. It is often impossible, however, to find the point of entrance. A small fissure, occurring in cold weather around the nose and angles of the mouth, has often been observed as a starting point for the infection. In the newborn — erysipelas neonatorum — infection of the cord-stump was formerly frequent. Morbid Anatomy. — The lesion is characterized by inflammation of the skin, with considerable exudation of fluid. The streptococci are ERYSIPELAS 41 present in large numbers in the lymphatics of the skin and underlying tissues, especially in the zone of spreading inflammation. They are also present in the adjacent non-inflamed parts. As the inflammatory process advances the cocci gradually die, and further extension at the periphery ceases. In some cases there may be suppuration. The streptococci may invade the various organs of the body, thus inducing septic complications. Symptoms. — Constitutional symptoms are usually manifest before the local symptoms. There is often a rigor followed by an elevation in temperature. Some enlargement of the lymph nodes may, perhaps, be detected in the region of the wound, if any exists. Soon there is a feeling of increased tension in the wound, which is hot, tender, and red. With the appearance of exudation the skin becomes red, smooth, tense, and edematous. Vesicles or blebs may appear. The swelling extends and the local redness shows a tendency to spread. The line of demarcation is sharp. If present on the extremities, the inflamma- tory process travels toward the trunk; and if on the face it often pro- gresses towards the scalp to halt at the hair line. If the scalp is in- vaded it frequently involves the entire scalp to halt again at the hair line posteriorly. If the disease spreads beyond the hairy scalp it is apt to sweep downwards over the back, fading gradually away. While in the scalp, local tenderness is marked, a physical sign often at vari- ance with the signs of the disease elsewhere on the body. In wander- ing erysipelas the process may involve large areas. In the facial form the swelling may be enormous, so that the eyes are closed, the nose enlarged, and the lips much thickened. The leukocyte count is from 10,000 to 20,000. Delirium may be present. At the end of four or five days the temperature falls. Erysipelas may reappear in the affected part or elsewhere. This tendency to recurrence is characteristic of the disease. At the end of ten days or two weeks recovery is usually com- plete. Some patients suffer from recurring attacks at certain times of the year on particular parts of the body. Among the complications may be mentioned spreading cellulitis (phlegmonous erysipelas); sloughing which may be extensive; septicemia, endocarditis, pneu- monia, meningitis, and nephritis. Prognosis. — The prognosis is generally good. The hospital mor- tality is about 7 per cent., but in private practice the death-rate is much lower. Treatment. — Isolation is regarded by some as important. Trans- mission of the disease by contact is of frequent occurrence, and those in attendance upon a case should not perform surgical opera- tions or attend cases of confinement. Drugs are not needed, except in the old and feeble, to whom stimulants may be given. Large doses of the tincture of chloride of iron, sometimes with quinine, have been recommended, but their value is doubtful. The local application of ichthyol, of weak solutions of carbolic acid or aluminium acetate is frequently serviceable, while cold boric acid solution, in frequent 42 ACUTE INFECTIOUS SURGICAL DISEASES application in moist gauze, gives the most comfort. It is important to remember that the disease is self-limited and generally runs its course despite any treatment. ERYSIPELOID. This is a form of dermatitis occurring usually on the finger or hand from inoculation by decomposing animal matter, and most frequently seen in cooks, butchers, and fish dealers. Rosenbach attributes the disease to an organism of the cladothrix group. The heat, swelling, pain, and redness are marked — the latter occurring at first as a line of demarcation, which may slowly spread over the entire hand. Involvement of the lymphatic ducts and glands may occur, but systemic symptoms do not follow. The treatment is largely expectant. TETANUS (LOCKJAW). Tetanus is an infectious disease usually following traumatic injur- ies, and is characterized by tonic spasms of the muscles, beginning with those of the jaw and neck, and progressively affecting the muscles of the trunk and extremities. The disease is incited by the tetanus bacillus. Etiology. — The general association of the disease with the pres- ence of wounds suggested its infectious nature a long time ago. Carle and Rattone in 1884 announced that they had induced the disease in rabbits by inoculations with material from a wound in an individual suffering from tetanus. The following year Nicolaier established the fact that inoculations of animals with earth from various sources often were followed by the development of tetanus. He described the tetanus bacillus, but was unable to isolate it in pure culture; this was done subsequently by Kitasato in 1889. It is slightly motile. It readily forms spores, and then presents the very characteristic "drumstick" appearance. The natural habitat of the organism has been shown to be the earth. It is found especially in garden soil and in the contents of dung heaps, where it probably exists as a sapro- phyte. By the employment of appropriate methods for the growth of anaerobic bacteria it may be cultivated artificially. The spores are very resistant, and may withstand boiling for five minutes; they may also be kept alive in a dry condition for many months without losing their virulence. Their resistance to antiseptics is considerable. The disease may be induced experimentally in animals by the usual methods of inoculation. The organisms remain confined to the point of inocu- lation. Feeding experiments have been unsuccessful. The incuba- tion period in animals varies from several hours to several days. The symptoms observed in inoculated animals are, in the main, those of the disease in man, the spasms beginning with the muscles nearest the seat of inoculation, but chiefly the muscles of mastication are TETANUS 43 involved. The disease is due to absorption of the toxic products of the organism from the wound which contains them. A study of the tetanus toxin shows that it is extremely poisonous, and that its intro- duction into the body is followed by the development of tonic spasms. The exact chemical nature of the toxin is unknown. Artificial im- munization of animals against tetanus has been studied, and by the injection of progressively increasing doses of tetanus toxin a moderate immunity may be produced. Inoculation of animals with attenuated cultures has also been followed by immunity. The degree of immunity acquired exists for several months. For a time the immune serum pro- tects susceptible animals against tetanus. It is especially efficient if injected before or soon after the inoculation, the degree of success depending largely upon the time that has elapsed since inoculation. When the symptoms of the disease are fully manifested, success is assured in only a small number of cases. There is no evidence that the antitetanic serum inhibits the growth of the bacilli. Although tetanus may occur anywhere, it has not everywhere been observed with the same frequency. It is more common in hot than in temperate climates, and in the colored than in the Caucasian race. Lombard states that in Iceland one-third of the general mortality, especially in the newly born, is from tetanus. It has been studied in epidemic form in infants (trismus nascentium). Out of 17,650 infants born (before 1882) in the Rotunda Hospital, Dublin, Clarke estimates that 2944 died of tetanus. In some of the West Indian Islands more than 50 per cent, of the mortality among the negro children has been due to this cause. Formerly the disease was very prevalent on the eastern end of Long Island. It is probable that the disease is always traumatic in origin. The wound of inoculation is sometimes too small to be found. Of 1751 cases of tetanus, 41.5 per cent, followed wounds of the hand or foot, many of which were the result of injuries from toy pistols; wounds of the limbs, face, and scalp are next in frequency. Infection is more apt to occur after punctured and contused than after incised wounds. Pathologic Anatomy. — The lesions are few and not characteristic. The recorded autopsies mention inflammation and degeneration of peripheral nerves, meningeal hemorrhages, and inflammatory changes in the sympathetic nervous system. Goldscheider and Flatau have described changes in the motor cells of the anterior horn which they consider characteristic. The cerebrospinal fluid in cases of tetanus has been shown by Stintzing to contain tetanus toxin. This author sums up his research concerning the pathogenesis of the infection in the following: "The tetanus bacillus produces toxins at the seat of infection. These toxins partly enter the circulation (in animals surely), and may become active through this channel; as a rule, how- ever, the toxins are carried along the nearest nerves, presumably in the meshes of the perineurium and endoneurium, to the spinal cord. 44 ACUTE INFECTIOUS SURGICAL DISEASES On reaching the subarachnoidal space of the cord they produce in animals their toxic action, at first at the point of entrance into the cord, and so cause the 'local' tetanus. If sufficient poison is brought to the spinal cord, it produces, next, a reactionary and, finally, general tetanus." Symptoms. — Most of the cases have an incubation period of about ten days; certainly four-fifths of the cases develop symptoms before the fifteenth day. Acute, chronic, and cephalic forms of tetanus are described. In acute tetanus the onset may be abrupt, but more often malaise, headache, chilly feelings or actual rigors occur, with some stiffness in the neck or a feeling of tightness in the jaws. Tonic spasm of the masseters (lockjaw) generally develops, and the eyebrows may be raised and the angles of the mouth drawn out, so that the face assumes the so-called sardonic grin — risw sardonicus. Finally, the muscles of the whole body may be affected, but those of back are most involved, so that during the spasm the body may be thrown into condition of opisthotonos. Flexion to one side, pleurosthotonos, is less common. Forward bending, emprosthotonos, is seldom seen. The arms, as a rule, are less affected. Paroxysms last a variable" time, during which there may be spasm of the glottis, dyspnea, and cyanosis. The paroxysms often are associated with agonizing pain. Usually the patient is covered with perspiration. Fever may be absent, slight, or in some cases the temperature reaches 105° or 106° F. The mind is not affected. Death generally occurs during a paroxysm, either from heart failure or asphyxia; in other cases it may be due to exhaustion. The disease is usually fatal in about 10 days. In chronic tetanus the symptoms are essentially the same as those observed in the acute form, but less severe. The disease may be prolonged for weeks. Cephalic tetanus is characterized by stiffness of the muscles of the jaw and paralysis of the facial nerve on the same side as the injury. Diagnosis. — In well-developed cases there is little chance for error in diagnosis. Prognosis. — The prognosis is based mainly on the period of incuba- tion and the severity of the symptoms. Statistics show that when the period of incubation is less than ten days the mortality is very high (85 per cent.); and also that the prognosis improves with each day beyond this period. Since the introduction of the antitoxin treatment the mortality has been reduced from about 90 to 40 per cent. Treatment. — In this we should endeavor (1) to destroy the bacteria at the seat of infection and thereby prevent a further production of toxins; (2) to eliminate from the body the toxins already elaborated from the primary lesion; (3) to neutralize and render innocuous the poison already absorbed; (4) to immunize the body after infection has taken place; (5) to overcome the symptoms induced by the action of the toxins. Thorough disinfection of the wound is very important. HYDROPHOBIA 45 The object should be not only to destroy the tetanus bacillus or its spores, but also saprophytic and pyogenic bacteria, which the experi- ments of Vaillard and Rouget have shown to favor development of the tetanus bacillus. Of the antiseptics most frequently used may be mentioned: iodine in 5 or 10 per cent, solution, also nitrate of silver 2 or 4 per cent.; bichloride of mercury solution (1 to 1000), to which has been added 5 per cent, tartaric acid or 0.5 per cent, hydro- chloric acid. The results following the use of tetanus antitoxin for curative purposes were rather disappointing when its administration was confined to the subcutaneous methods. Recent procedures involving the direct contact of antitoxin and the part of the nervous system affected, have yielded results which are far more promising. Park and Nicoll have reported a suggestive series of experiments on animals where the antitoxin was used intraspinally. In a similar form of treatment they report few human cases that recovered. They advise the intraspinal injection at the first possible moment following the onset of tetanus, of from three to five thousand units of antitoxin. This antitoxin should be introduced by gravity and very slowly, if possible while the patient is under an anesthetic. If the amount of spinal fluid is small the quantity of antitoxin must be reduced. In addition to the use of tetanus antitoxin, every effort must be made to prevent the occurrence of convulsions by the maintenance of absolute quiet and the administration, when necessary, of bromides, chloral, morphine, or opium. HYDROPHOBIA. Hydrophobia is an infectious disease, occurring chiefly among the carnivora, especially the dog and wolf. The disease is also known as rabies and lyssa. Infection is carried by the bite of a rabid animal or by a wound being licked by such. Etiology. — Rabies occurs in all countries. In man the period of incubation varies from fifteen days to seven or eight months or longer, but the average period may be taken as forty days. The differences in the incubation period are partly due to the age of the patient, the part involved, and the severity of the wound. In children the period of incubation is more brief than in adults. Wounds about the face and head are regarded as especially dangerous. The bite of the wolf is more serious than of other animals. The infective agent in the saliva of the rabid animal passes from the wound, and is carried along the nerves to the central nervous system. It may be present in the saliva of the dog from three to five days before the symptoms of the disease appear in the dog. In 1903 Negri found in the ganglion cells of the Hippocampus major cerebral cortex, medulla, and elsewhere in the nervous system rounded bodies 1 to 23/x in diameter resembling protozoa, which 46 ACUTE INFECTIOUS SURGICAL DISEASES stain readily and consist of a rounded or oval homogeneous basement substance containing a central body surrounded by variously shaped granules. These "Negri bodies" have been found in nearly all cases of street rabies examined for them, and in no infective or other disease than rabies, and therefore undoubtedly occupy a specific etiological rela- tionship to hydrophobia. Morbid Anatomy. — The lesions are limited to the central nervous system. In the medulla and pons, and occasionally in the spinal cord, may be seen small hemorrhages, accumulation of leukocytes in the perivascular spaces about the bloodvessels and ganglion cells. Some of the ganglion cells show chromatolysis, and the Negri bodies may occupy central or peripheral positions in them. Symptoms. — Three stages are described. First, prodromal, in which there may be pain in the wound and in the nerves along the injured limb. Manifestations of nervous irritability soon appear, associated with an increase in the reflexes. There may be slight fever. The patients at this period are often melancholic, and there may already be some suspicion of difficulty in swallowing. Second, stage of excite- ment, in which there are great excitability and hyperesthesia. There are spasms, especially of the muscles of deglutition and respiration. Delirium may be present. Spasms may be induced by the slightest causes. In the intervals the patient is clear-minded and calm. The temperature is between 95.5° and 102° F. In two or three days the patient passes into the third or paralytic stage, in which the reflexes are diminished, weakness and paralysis may be present, convulsions occur, and finally coma and death supervene. The duration of the disease is from five to ten days. Death invariably results when once the disease is established. Whenever a person is bitten by an animal that is suspected to be suffering from rabies, the animal may be carefully watched for mani- festations of the disease. Death will usually take place within five days. If the animal has been killed, pieces of the cord or medulla may be taken and inoculated beneath the dura of a rabbit. Symptoms will appear within three weeks. Recently it has become the common procedure to kill the suspected animal and determine the diagnosis of rabies by the presence of Negri bodies in the brain or medulla. In this way a positive diagnosis may be made with the least loss of time. Treatment. — Before Pasteur's method was developed, the only means by which the development of the disease could be prevented in those who had been bitten by a rabid animal was cauterization of the wound. The very long incubation period in the human being of from fifty to ninety days in the average case affords time for artificial immuniza- tion against the disease. Really wonderful results have been obtained by this procedure, if treatment is commenced in time. Following the onset of symptoms the disease is regularly fatal. Immunity is obtained by daily injections of toxin of increasing ANTHRAX 47 virulence. A relatively inert virus is used in the initial dose until on or about the eighteenth day full strength virus is injected. Therefore, by the time the disease would appear the resistance will be sufficient to withstand it. ANTHRAX (MALIGNANT PUSTULE, WOOL SORTER'S DISEASE). Anthrax is an acute, local, or general infectious disease, induced by Bacillus anthracis. It occurs with great frequency among the herbivora, especially sheep and cattle, from which it is readily com- municated, directly or indirectly, to man. Etiology. — It is to the studies of Rayer and Davaine, Pollender, Pasteur, and Koch that we owe our knowledge of the infectious agent of anthrax. The anthrax bacillus readily forms spores, which are very resistant to heat and chemical agents. They withstand the temperature of boiling water for several minutes. They are not killed by gastric juices. Outside of the body the spores probably live for a long period of time. Anthrax is more commonly met with in Europe and Asia than in this country. Animals are sometimes inoculated by the bites of insects, but more often by swallowing the infectious agent. Those who are engaged in handling hides are often infected on the hands or face. Butchers sometimes are infected by handling contaminated meat. Wool-sorters, on the other hand, are more liable to inhalation infection. Symptoms. — Several varieties of the disease are recognized, accord- ing to the portal of entry of the anthrax bacillus. The infection may be external, through the skin; internal, through the respiratory organs or intestine. The characteristic lesion of the external form is the pustule, which is usually situated on the hands, arms, face, or neck. The period of incubation is two or three days. The external lesion begins as a papule, which soon becomes vesicular. The tissues become infiltrated with exudate, so that within forty-eight hours there is a dark-brown or brownish-red eschar, often surrounded* by a fine vesicular eruption. The lymph nodes of the region become enlarged and painful. There is a variable amount of fever, although the temperature may fall to subnormal before death occurs. Death may occur within three or four days. In the majority of anthrax infections the symptoms are less severe. In these cases there may only be slight swelling about the local lesion. The disease sometimes appears, especially about the face, as an extensive edema without papules or vesicles. This is known as malig- nant anthrax edema. The fatal cases of external anthrax are generally those in which infection has taken place on the face or neck. Intestinal anthrax results from swallowing infected material. There may be a chill, often followed by diarrhea, fever, and other evidences -48 ACUTE INFECTIOUS SURGICAL DISEASES of an acute infectious disease. The spleen is enlarged. The bacilli may be found in the blood shortly before death. In the respiratory type the symptoms are usually severe from the beginning — chills, pain in chest, back, and legs, hurried respiration, fev?r, and cough, with signs of bronchitis. Death may occur within thirty-six hours. The outlook is best for cases of external anthrax, especially if the infection occurs in the extremities. In this class the mortality does not exceed 5 per cent. When the lesion is on the neck or face the mortality rises to about 30 per cent. Internal anthrax shows a much higher mortality. Treatment. — The primary lesion in its earliest stages may be de- stroyed by the Paquelin cautery or caustics. At one period excision of the pustule was practised. More recently this procedure has been advised against, since the invasion of the body at large seems to be more apt to occur. Disinfection of the wounds by means of packing with wet formalin gauze (1 to 50) is the most effective treatment. The toxemia should be combatted with stimulants, food, and measures to promote rapid elimination of the poison through the skin, kidneys, or alimentary canal. MALIGNANT EDEMA. Malignant edema is an' acute, local, infectious process, accom- panied by tissue emphysema and gangrene, and caused by the bacillus of malignant edema, which is found in garden soil, dung, and various putrefying substances. The bacillus is anaerobic and under unfavorable conditions of growth develops large spores, which have a high power of resistance. The infection may be introduced by a sharp-pointed garden tool or even a needle, but the disease occurs most commonly when dirt con- taining the bacillus enters a severely contused wound. Particularly is this true in extensive injuries such as gun-shot wounds combined with loss of blood ; under these circumstances the invasion of the body by the organism is more likely to occur. Early in the process the skin becomes a dirty, brownish-red color, with distended veins filled with stagnating blood. The tissues become edematous and infiltrated with gases, giving rise to emphysematous crepitation on palpation. A scant serosanguineous discharge exudes from the wound, accompanied by a characteristic, offensive odor. Gangrene develops in the wound and spreads rapidly. The neighboring lymph-nodes are swollen and the patient shows signs of septic absorp- tion — fever, prostration, dry, heavily-coated tongue, rapid pulse, with delirium followed by coma. Death may occur in from forty-eight hours to three or four days, an entire extremity being meanwhile involved in the disease. Prognosis. — The prognosis is bad. The mild cases occasionally recover after multiple incision and asepsis; but amputation performed GLANDERS l!) early and as high up on the extremity as possible, is usually indicated. In animals, immunity to this infection has been produced by repeated injections of sterilized or filtered cultures of the organism or the filtered serum from immune animals. GLANDERS (FARCY). Glanders is an infectious disease which chiefly affects horses, mules, and asses. It is found also in man as a result of direct inoculation on some wound of the skin or other part with the discharges or diseased tissues from an affected animal. Therefore it is especially frequent among grooms and others whose work brings them into contact with horses. Etiology. — The bacillus of glanders was discovered by Loeffler and Schutz. Morbid Anatomy. — When limited to the nose the disease is called (/hinder*; but if present beneath the skin, it is designated farcy. The lesions consist of granulomatous tumors, which tend to break down rapidly and form ulcers on mucous membranes and abscesses beneath the skin. The lungs are almost invariably involved. Less frequently other organs show characteristic lesions. These consist of larger and smaller white or yellowish-white nodules sharply cir- cumscribed and surrounded by a hemorrhagic zone. Beyond this an area of pallor is sometimes seen. They are situated around the blood- vessels, and consist of polymorphonuclear leukocytes with broken down cells. Symptoms. — Glanders infection in man is either acute or chronic in its manifestations. Acute Glanders. — The incubation period is generally three to four days. At the inoculation seat there are swelling, redness, and signs of lymphatic involvement. In three or four days the nodules in the mucous membranes of the nose begin to break down, with the discharge of muco-pus. There is considerable swelling of the nose, and an eruption of papules and pustules is common on the face. The lymph nodes of the neck are usually swollen. The disease runs a course of about ten days, many of the cases dying with pneumonia. All the cases terminate fatally. Chronic Glanders. — This may last a long time, and the diagnosis is not often made. The symptoms are those of a chronic coryza. Ulcers may be found in the nose. Acute Farcy. — This is the result of inoculation into the skin. Intense local inflammation occurs; the lymphatics become involved, and along their course nodules — farcy buds — may be felt. Many of these suppurate. In addition to these lesions often there is a pustular erup- tion resembling that of varicella. The disease pursues a febrile course like that of severe typhoid or a septic infection. Pains and swellings in the joints may be present. The nasal mucous membrane is free 4 50 ACUTE INFECTIOUS SURGICAL DISEASES from ulcers. The prognosis is bad, most of the cases dying within two weeks. Chronic Farcy. — In this form the nodular tumors are usually found in the extremities. Many of them break down, resulting either in abscess or ulcer formation. The lymphatics are not specially involved. Recovery is possible. Diagnosis. — The diagnosis may be made by Straus' inoculation test. It consists in the peritoneal inoculation of male guinea-pigs with suspected material. If the inoculated material contain Bacillus mallei there will be swelling of the testes as early as the third day, and swelling and ulceration of .the scrotum by the fifth or sixth day. Autopsy often shows the presence of glanders nodules in the omentum, spleen, and liver, and an inflammatory purulent or caseous exudate in the tunica albuginea. Mallein — the glanders bacillus toxin — is now used for diagnostic purposes in horses. Treatment. — The lesion should either be excised or cauterized if the case is seen early. The farcy buds should be opened and disin- fected with formalin. BACILLUS AEROGENES CAPSULATUS (GAS BACILLUS) INFECTIONS. It is known that various bacteria may be concerned in producing gas in tissues where it does not normally exist. From the investi- gations of the last ten years, however, we know that Bacillus aerogenes capsulatus, which was discovered by Welch in 1891, is the one most frequently associated with such conditions. This is an anaerobic bacillus. Spore-formation is inconstant. The natural habitat of the organism is the soil and intestinal canal. Brooks has also found it in the male urethra, the vagina, and nasal cavities. It is common experience to find the bacillus in cadaveric decompo- sition; its natural occurrence in the intestine explains this phenomenon. Bacillus aerogenes capsulatus has been observed under a variety of pathologic conditions associated with the formation of gas in the tissues. It may also induce septicemia, in which gas bubbles are found in the blood. The presence of these gas bubbles in organs gives an ap- pearance which is commonly designated foamy organs (Schaumorgane). Gas-bacillus infection often follows wounds to which dirt has gained access, such as compound fractures and injuries of different kinds. Sometimes, as noted by Bloodgood, the organism does not lead to gas formation in the involved or other tissues. Frequently, however, it induces emphysematous gangrene, most of the cases involving the extremities. Gas may appear in the tissues as early as eight hours after the injury. The lesions consist of necrosis, gaseous distention of the tissues, infiltration with blood, and the exudation of serum. The majority of the cases die from the results of general infection. On the other hand, when the disease is promptly and adequately treated, GANGRENE 51 recovery may occur. Of the cases collected by Welch, 59 per cent, terminated fatally. Gas-bacillus infection may also occur in the genitourinary organs, especially in pregnant and puerperal women after abortion. Gastro- intestinal and other forms of infection have been described. Diagnosis. — The disease generally begins as any other cellulitis. It differs from the ordinary form of cellulitis, however, by its rapid extension, the presence of a crackling sensation on pressure, and the rapid development of grave septic symptoms. The presence of emphy- sema in the tissues will, of course, always excite suspicion. It is important in such cases to make cover-slip preparations with material from the infected parts. The presence of rather large, straight, or slightly curved bacilli, which stain by Gram, especially if capsulated, is very suspicious. This should be further confirmed by introducing some of the infected material into the circulation of a rabbit, prefer- ably into one of the ear veins. After a delay of about ten minutes which is necessary to insure distribution of the injected material throughout the body, the animal should be killed and placed in a warm room or incubator. In a few hours examination, if Bacillus aerogenes capsulatus be present, will reveal the characteristic appear- ance of "foamy organs." Treatment. — The treatment consists of free incisions, removal of the gangrenous cellular tissue, and packing the wounds thus formed with wet formalin gauze (1 to 50). Stimulants, an abundance of nourish- ing food, and measures to favor rapid elimination of the toxins also are indicated. GANGRENE. The term gangrene is applied to the process resulting in the death of tissue en masse. Etiology. — The causes may be divided into: (1) Exciting, which consist of agents directly destroying the vitality of the tissues, or of those which act directly by cutting off their nutrient supply; and (2) predisposing causes. Some exciting causes are in themselves alone cap- able of causing gangrene. For others, however, to become operative, predisposing causes which impair the vitality of the tissues are necessary. These are old age, feeble action of the heart, chronic congestion of a part, deteriorated blood, as in diabetes and Bright's disease, and the impair- ment or loss of nerve influence from injury or disease of the nerve centres or nerve trunks. These all may be narrowed down to impair- ment in nutrition of the tissues largely through cutting down of blood supply as in an obliterating endarteritis. Of the exciting causes those which act directly by destroying the vitality of the tissues are: chemical, as strong acids or alkalies: bacterial and animal poisons: mechanical, as severe crushing of a part; and thermal, as extremes of heat and cold in burns and frost-bites. 52 ACUTE INFECTIOUS SURGICAL DISEASES Those causes which act indirectly by cutting off the nutrient supply of tissues are, obstruction to the arterial supply, as from ligature, em- bolism, thrombosis, arterial sclerosis; obstruction to the capillary circulation from thrombosis or pressure, as in bed-sores or pressure from a splint or new growth; obstruction to the venous return, as in strangulated hernia, paraphimosis, tight bandaging, etc. Clinically, gangrene may be divided into dry and moist forms. The amount of fluid in the tissues at the time gangrene supervenes and the degree of bacterial infection being the factors which influence the type of the process. The clinical types of gangrene which are usually dry, are senile gangrene from arterial scleroses, embolism, or ligature of a main artery, frost-bite, and Raynaud's disease. The others, which are often moist, are inflammatory, traumatic, hospital and diabetic gangrene, phage- dena, bed-sores, carbuncle, cancrum oris, and noma. Symptoms. — In the dry form of gangrene the onset and develop- ment are very slow. The part first becomes pale and mottled, then dry, shrivelled, and hard, turning to a brown or black color and resembling a mummy. As bacterial processes are not here active, there is no putrefaction, and the odor, so offensive in moist gangrene, is absent. In the moist form of gangrene the tissues, at the onset, are full of blood and fluid, the process is rapid, with little time for the evapora- tion of fluids, and bacterial activity is pronounced and often extreme. During the early stages the part becomes swollen, dusky red in color, edematous, and painful. Later all sensibility is lost, it becomes colder than natural, and the color changes to a dark greenish-purple tint, and then becomes black. Bloody bulla? form and the epidermis peels off, leaving a moist surface. Putrefactive gases collect in the tissues and cause crepitation when the part is pressed. The soft parts become semisolid or liquid, and separate from the bone as a slimy, foul-smelling dark mass. As a result of the absorption of septic products the patient may have fever, often of the asthenic type, resulting in exhaustion or death. These two forms may result in the formation of a line of demarca- tion, or a progressive advance with no definite limitation. In the latter case, occurring most commonly in spreading trau- matic gangrene, the process advances rapidly up an extremity reaching the trunk, when the patient falls into a typhoid condition and dies. No line of demarcation forms and operative treatment consists of amputation, early and far removed from the injury. There is a great tendency in these cases for gangrene to occur in the flaps after ampu- tation. If the process of gangrene is arrested in time, the so-called line of demarcation forms at the junction of the living; and dead tissue; and through tissue autolysis, physical disintegration occurs. This gradually divides all the structures of the part, skin, subcutaneous tissue, tendons, and vessels. Not alone autolytic ferments but other cellular ferments from GANGRENE 53 leukocytes operate in the tissue liquefaction. Step by step with the tissue disintegration, granulations form on the living side of the line of demarcation. The entire process of tissue Liquefaction, tissue growth, and separation is similar to that which occurred in an abscess cavity. Therefore if the operative factors that produced the gangrene are held in abeyance, repair may follow the natural amputation of the part. In the majority of instances, especially with predisposing fac- tors operating, if there is no surgical interference, a more or less stationary condition of the tissues develops. On the stump there are areas of granulation tissue with masses of dead tissue still attached. From time to time local infections occur leading often to the death of more tissue. Finally the individual is overcome by the various factors and dies. Treatment. — While the details of the treatment of gangrene must vary with the type of the process and its cause, the following general principles may be adhered to in all cases: (1) Remove, where possible, the cause. (2) Combat threatened gangrene by maintaining the warmth of the part, improving the circulation by elevating the limb, and by gentle friction where there is venous congestion. (3) When gangrene has actually occurred, check its spread if possible; promote separation of the dead from the living part or remove it by amputation; control, as far as possible, the formation of the products of putrefaction by keeping the part dry, support the patient's strength, counteract the deleterious effects on the constitu- tion from the absorption of the septic poison, and soothe the pain by opium. Although the general outline of symptoms and treatment already given are applicable for most of the forms of gangrene, a certain amount of variation occurs in the various clinical forms of gangrene which necessitate brief mention. Clinical Types. — Senile Gangrene. — Senile gangrene, rarely occur- ring before sixty years, is usually caused by a narrowing of the arterial lumen as a result of advanced sclerosis in connection with weak heart action, the process frequently having its origin in some slight local injury (Figs. 5 and 6). It usually starts in the toes, and may extend to the ankle or knee before a line of demarcation is formed. The gangrenous extremity may then be cast off or the patient may succumb from exhaustion and septic absorption. The affected parts are occasionally allowed to separate spontaneously. The greatest care is employed to cleanse the part and keep it surgically clean thereafter. Dryness is essential, and after an antiseptic deodorizing pow r der is applied the part is wrapped up in a thick layer of absorbent gauze. Amputation, if resorted to, is usually done above the bifurcation of the popliteal artery to be above the obstruction to the lumen. The age and conditions of arteries and heart in these patients, however, make the conditions for operation far from favorable. 54 ACUTE INFECTIOUS SURGICAL DISEASES Presenile Gangrene.— While it has long been recognized that senile gangrene occurs most commonly as the result of interference with the nutrition of a part through the diminution of the blood supply following arteriosclerosis, it is only recently that the fact has been appreciated Fig. 5. — Senile gangrene of foot. that arteriosclerosis may occur in earlier life to operate similarly as a cause of this form of gangrene. This form of gangrene is prone to occur in Russian Hebrews even below thirty years of age. To this process, occurring in the young, the term presenile gangrene has been applied. Fig. 6. — Senile gangrene. Serial section showing constriction of vessel lumen. This form of gangrene, like the senile, is apt to be dry, and, with the exception of the age of the patient, differs in no essential way from the senile form, except that the prodromal symptoms may exist for months or years before complete gangrene finally occurs as a result of thrombosis in the narrowed lumen of the affected vessels. GANGRENE Ischemic Gangrene. — In gangrene due to embolism, thrombosis, or a ligature, the extent of the process depends upon the site of the exciting cause; and the process is usually of the dry type. In these eases it is necessary, before resorting to amputation, to wait until an arrest of the proeess takes place. By this means the proper site for amputation is best determined, and an opportunity is given to the collateral circulation to establish itself in the tissue which is to be used for flaps. Gangrene from frost-bite is usually seen in the fingers, toes, ears, and nose. It is usually typical of the dry type. The treatment in the early stage consists of rubbing the part with snow or cold cloths, gradually making the applications warmer. Elevation of the part, warm, loose bandaging, warmth, and general stimulants are then employed. If gangrene has completely developed, the part may be kept dry, dusted with an antiseptic powder, and allowed to separate at the line of demarcation, or be removed by amputation. In Raynaud'* disease, caused probably by some disturbance of the vasomotor nerve centre inducing spasm of the arterioles, or in some cases by a peripheral neuritis, the parts, generally the fingers, become first white, cold, and insensitive, then swollen, red, dusky and painful, and later black, the process, if continuing further, terminating in dry gangrene. Until the last stage is reached relief may be obtained by local warmth and loose bandaging, the constant descending electric current, or placing the parts in an electric bath, with the use of general tonics. Ergot Gangrene. — Ergot gangrene occurs from tetanic contraction of the arterioles, produced by the contamination of rye bread with claviceps purpurea. The process, which attacks the fingers, ears, or nose, is preceded by formication, numbness, and pains in the parts affected. It is advisable to wait for the formation of a line of demarca- tion before operating on these cases, and then to amputate immediately above the disease. Carbolic Gangrene. — Carbolic acid, even in comparatively weak solutions of 2 to 4 per cent, is liable to induce dry gangrene when applied as a moist dressing to the fingers or toes for a prolonged period of time (Fig. 7). Before amputation is done a distinct line of demarcation should present itself, and in some instances the dead tissue may be allowed to separate naturally from the living, the bone being then nipped off high up with forceps. Traumatic Gangrene. — Ande spreading traumatic gangrene is an example of moist gangrene occurring in tissues which have been badly crushed and lacerated and infected with virulent pathogenic microbes. These are often anaerobic and sometimes gas-producers, and include the Bacillus aerogenes capsulatus, Bacillus of malignant edema, and colon bacillus, all of which are capable of manufacturing excessively toxic products. The process is exceedingly rapid; putrefactive gases in the tissues may give rise to emphysematous crackling, and the 56 ACUTE INFECTIOUS sih'<;J(AL blsEAsES course of the lymphatics may be traced by red lines in the superficial tissues. The edges of the wound are swollen, everted; there is a slight, fetid discharge of brownish serum, hut no pus. All such wounds should be thoroughly cleaned, trimmed free of tissue shreds, the crevices well drained, exposed to air, and washed with hydrogen peroxide. (langrene once having developed, the patient's only hope lies in immediate amputation as high as possible above the gangrenous part, strict antisepsis of the field of amputation being maintained. To combat the overwhelming constitutional effect of the absorbed poisons stimulants should be administered. Fig. 7. — Carbolic acid gangrene. Closely allied to this form of gangrene is the type known as inflam- rnatory gangrene, or gangrenous cellulitis, occurring usually in the subcutaneous tissue as a result of infection by the Streptococcus pyogenes. The tissues, which usually have a low routing power in these cases, die as a result of tension and bacterial poisons. The con- dition may progress rapidly, and the exudate after incision may be serous without any evidence of pus. Treatment must be prompt and energetic, consisting of multiple free incisions followed by copious antiseptic irrigations. Failure to stem the advance of the process by these means must be followed by GANGRENE 57 amputation. The constitutional effect of the absorbed poisons is to be combatted by the use of stimulants and antistreptococcic serum. Very closely allied to these forms are cancrum oris and noma, occur- ring as sloughing ulcers in the mouth and vulva respectively, as a result of capillary thrombosis caused by virulent bacterial infection in debilitated patients after infectious diseases. The treatment for these conditions is the same as that of the phagedenic gangrene just described. Diabetic Gangrene. — This occurs in diabetics as a result of accom- panying endarteritis, and lowered resistance of poorly nourished tissues by which the growth of bacterial organisms is aided. For this reason diabetic gangrene, which resembles the senile form in many ways, is usually moist. It usually starts in the lower extremity as a result of a slight wound. It may spread rapidly or slowly. If the spread is slow, the process should be treated expectantly by local measures. If the advance is rapid, amputation at the lower third of the thigh should be performed. In the meantime measures directed toward the constitutional condition of diabetes should be employed with special reference to the avoidance of diabetic coma following operation. Bed-sores occur in those whose tissues are partially devitalized by acute fevers and chronic diseases. With loss of sensation through poor inervation, continued pressure may lead to a bed-sore. This is a frequent occurrence in those who have received an injury to the spinal cord. The direct cause is usually pressure over a bony prominence. The skin becomes a dusky-red color, purplish, and finally black. A slough forms which separates, and the process may extend centrifugally or deeply until it reaches periosteum or bone. Prevention of the condition is most important by the regular chang- ing of the patient's position, the use of ring pads and air cushions, thorough cleanliness, rubbing with alcohol, drying, and the application of antiseptic dusting-powders. The ulcers, once formed, are to be treated by regular surgical methods. CHAPTER IV. CHRONIC INFECTIOUS SURGICAL DISEASES. TUBERCULOSIS. Tuberculosis is an infectious disease common to man and cer- tain animals. It is caused by Bacillus tuberculosis, and is character- ized by an exudative and productive inflammation in which necrosis and caseation of the involved tissues commonly occur. The typical morphologic lesions consist of small nodular growths called tubercles. Bacillus Tuberculosis. — The contagious idea of phthisis dates back to the time of Galen, who included it among those diseases which could be communicated from one subject to another. In the latter half of the fifteenth century the belief occupied a prominent position in the minds of many in Italy, judging from the sanitary regulations then in force with reference to the disease. But it remained for Villemin to establish definitely, by experimental studies, its infectious nature. His first communication appeared in December, 1865. For the dis- covery of the inciting agent we are indebted to Koch, whose announce- ment appeared March 24, 1882. The tubercle bacillus does not form spores, and grows best in the presence of oxygen. Dried tuberculous sputum may contain living tubercle bacilli after many months. The organism is readily killed at high temperatures; its viability is also affected by desiccation, putrefaction, and particularly sunlight. Five per cent, carbolic acid kills the organism in thirty seconds; 1 to 1000 solution of mercuric chloride in ten minutes; and absolute alcohol in five minutes. Tuberculosis has been well studied experimentally in animals. Guinea-pigs are very susceptible to inoculation with cultures of material containing tubercle bacilli. Variations in virulence have been noted. Tubercle bacilli obtained from cold-blooded animals, or from cattle, or birds show cultural and pathogenic differences from those of human derivation. Distribution of Bacilli. — They are present in all tuberculous lesions, although their demonstration may sometimes be very difficult. In actively developing tubercles they are present in great numbers; but in some lesions, such as tuberculosis of lymph nodes and joints, they are generally present only in small numbers. Outside of the human body the organism is also widely distributed. This is not surprising if we recall the estimate of Nuttall that the twenty-four-hour sputum of a consumptive patient may contain between 300,000,000 and TUBERCULOSIS 59 4,000,000,000 tubercle bacilli. In its moist condition sputum is devoid of great danger, hut in drying it is eventually converted into dust that is spread in all directions by currents of air. Perhaps nothing more forcibly emphasizes the danger of infection from such sources than the investigation of Straus, who demonstrated the presence of bacilli in the nasal mucus of various healthy individuals frequenting the wards of hospitals in Paris. Cornet showed that the dust from the floors and walls of dwellings in which tuberculous persons were living often contained virulent tubercle bacilli; and Hance found that the dust of one in five cars was contaminated with them. Baldwin has recently shown that tubercle bacilli are not uncommonly present on the hands of tuberculous patients who are not careful in the use of handkerchiefs, clothing, or cuspidors*. The Tubercle. — The local lesions induced by the tubercle bacillus are often in the form of circumscribed nodules, which are called tubercles. Such localized tuberculosis may remain as a local inflamma- tion; or by metastasis it may give rise to the development of tubercles in other parts of the body. The tubercles are small nodular bodies, either gray and translucent, white or yellow, and opaque. The action of the tubercle bacillus in the body is twofold; on the one hand it induces proliferative changes and leukocytic emi- gration; and, on the other hand, it causes degenerative changes which result in necrosis. The earliest reaction consists in pro- liferation of the connective-tissue cells. These become changed in form into the so-called epithelioid cells. Hand in hand with these changes new reticulum is formed. Giant cells are frequently present. Old bloodvessels are usually obliterated and new ones are not apt to form. With the elaboration by the tubercle bacilli of poisonous products which act upon the cells, a process of coagulation necrosis, or caseation, develops. This begins in the centre of the tubercle, gradually extending to the periphery. Partial necrosis of giant cells also is observed. The cheesy masses may undergo softening, fibrosis, or calcification. Under the microscope these typical tubercles usually consist of small round cells, epithelioid and giant cells, and a reticulum. The caseous portion occupies the central part, perhaps with giant cells. Outside of this is a zone of round and epithelioid cells, and bevond this an area made up almost entirely of small round cells. Instead of such focal lesions as tubercle, large areas of tuberculous inflammation may develop, showing more or less caseation with an irregular sprink- ling of epithelioid and round cells. But whatever the morphologic character of the lesions, tubercle bacilli are always present. Occurrence in Various Organs. — Tuberculosis may occur in any organ, but some tissues are more commonly affected than others. Thus the lungs, pleura, lymph nodes, peritoneum, bones, joints and testicles are more commonly involved, whereas tuberculosis of the muscles, fasciae, liver, spleen, ovaries, and pancreas is rare. In adults the lungs may be regarded as the seat of election; and in 00 CHRONIC INFECTIOUS SURGICAL DISEASES children the lymph nudes, bones, and joints. Osier states that in 1000 autopsies, 275 eases were tuberculous, with involvement of the lungs in all but two or three. The frequency of involvement of other organs was as follows: Intestine, peritoneum, kidneys, brain, spleen, liver, generative organs, pericardium, and heart. Surgical tubercu- losis has a somewhat different distribution. Of SS73 patients of the Wurzburg clinic, 1287 were tuberculous, with the following distri- bution: Bones and joints, 1037; lymph nodes, 196; skin and con- nective tissues, 77; genito-urinary organs, 20; mucous membranes, 10. It is generally agreed that tuberculosis is rare during the first months of life. Most of the cases occur between the ages of ten and forty. Modes of Infection. — Certain well-defined forms of tuberculosis are recognized, depending on the point of entrance of the infectious agent. The common primary localization of tubercle in the lungs indicates that in a large proportion of cases infection takes place by inhalation. The cases of primary .intestinal tuberculosis have usually followed the ingestion of infected milk. Secondary lesions in the intestines are common, due largely to the swallowing by consumptive patients of infected sputum. Cases of accidental inoculation have been re- ported especially among those working with infected tissues, such as pathologists, butchers, etc. Congenital tuberculosis is very rare; most authorities concede that the tubercle bacilli are transmitted only occasionally from parent to offspring. Predisposing Factors. — There is general agreement that under certain conditions leading to extreme impurity of the air tuberculosis becomes frequent. Absence of sunlight and ventilation are important predisposing factors. Formerly accorded a most important role, inherited predisposition has been less insisted upon within recent years. Those who follow certain occupations have been shown to contract the disease more readily than others. The influence of sex is very slight. It is generally claimed that an intimate association exists in many cases between trauma and the subsequent development of a tubercu- lous lesion in or about the injured part. It is of interest to point out that the occurrence of tuberculosis at the site of a simple fracture is a surgical curiosity. Simple fractures are of common occurrence in those obviously tuberculous as well as those free of the disease. The above seems to contradict the statement that injury as such is a predisposing factor as regards the location of the infection. In some cases, on the other hand, generalized tuberculosis has followed injury to tissue in which there was only local tuberculosis. Bacteriologic Diagnosis. — Bacteriologic examination always con- stitutes one of the most important features in the diagnosis of any case of tuberculosis. Examination of Sputum. — Preferably the morning sputum is col- lected. The fine, cheesy particles should be carefully selected, as they are more apt to contain the tubercle bacilli. SYPHILIS 61 Examination of Urine — In cases of suspected genitourinary tuberculosis the urine should be obtained by sterile catheterization, centrifuged, and the sediment collected. It is usually very difficult to find tubercle bacilli in urinary sediments. Moreover, unless special precautions are taken, the smegma bacillus, which is normally present about the external genitals, and has tinctorial reactions similar to the tubercle bacillus, may be mistaken for it. The safest way is to have recourse to guinea-pig inoculations, either intraperitoneal or subcu- taneous. Examination of Serous Exudates. — The search for tubercle bacilli in the exudates of tuberculous pleurisy, peritonitis, meningitis, or arthritis is often uncertain and tedious. The exudates are to be re- moved with bacteriologic precautions and collected in sterile recep- tacles. Fluid may be obtained from cases of meningitis by lumbar puncture. For microscopic examination it is important to centrifugate the fluid because the tubercle bacilli are almost always present in small numbers. Guinea-pig inoculation is the best test. Biological Diagnosis. — Von Pirquet has suggested a serum test which when negative is of extreme value but when positive affords little assistance to the surgeon in deciding upon the diagnosis of any par- ticular lesion. This is because of the extreme sensitiveness of the test and the frequency of tuberculosis which always results in a positive reaction. SYPHILIS. Syphilis is a specific constitutional disease limited to man, the virus of which may be transmitted by inoculation to some of the lower animals. Acquired syphilis and congenital syphilis are spoken of, depending upon whether the disease was acquired before or after birth. There is but little question that the organism dies promptly away from living animal tissues unless kept moist and warm. There- fore very direct contact with an infectious individual is practically essential for inoculation to occur. If during pregnancy the mother is infectious the fetus rarely escapes acquiring the disease. Similarly during life an individual rarely escapes infection if his or her injured tissues come in contact with a syphilitic lesion in an infectious stage. Syphilis is acquired by contact with objects, drinking cups, dentists' tools, etc., very recently contaminated and on which the Spirochete pallida chances to survive. Such infections, however, are rarities. Etiology. — The disease prevails throughout the civilized world. Until recently the cause of this disease was unknown; but in 1905 Schaudinn and Hoffman discovered a slender spiral organism, the Spirochete pallida, which has been found in syphilitic lesions and in these only, and which has been obtained from the scrapings of chancres, enlarged glands, mucous patches, and flat condylomata in syphilitic cases, and may be readily demonstrated in these scrapings, and occa- sionally in scrapings from tertiary lesions by means of the Giemsa 62 CHRONIC INFECTIOUS SURGICAL DISEASES stains. To demonstrate the organism in tissues the method of Livaditi is usually employed. The Spirochete pallida varies in length from 4 to 14,u, has from three to twelve curves, and pointed ends. The virus gains entrance to the body by contact with some abraded surface. As in the great majority of instances this occurs on the genital organs during sexual intercourse, the disease has been generally regarded as a venereal affection. It must be "remembered, however, that inoculation may occur at any point and in a great variety of ways, and many examples of non-venereal infection are observed. Acquired Syphilis. — Symptoms. — Primary Period. — The seat of in- oculation, after a certain period of incubation varying from one to six weeks, presents certain characteristic tissue changes resulting in the formation of the chancre or initial lesion. This, in the majority of instances, is an elevated indurated nodule, presenting on its surface an area of indolent ulceration. The lesion is, as a rule, single and painless, and is often discovered by accident. In women the initial lesion is often overlooked. As the chancre develops the anatomically related lymph nodes show a gradual and painless enlargement. In initial lesions occurring within the mouth, this glandular enlargement is often the first symptom of the disease which attracts attention. Secondary Period. — After development of the chancre and enlarge- ment of the neighboring lymph nodes, there is a second period of incubation, during which no further manifestations of the disease ap- pear. The length of this period varies from two weeks to six months, the average being about four or five weeks. At the end of this period the so-called secondary symptoms appear. These are a general feeling of malaise, fever, headache, and pains in the long bones, especially those of the lower leg. The pharynx is congested and sore; there appears a faint generalized eruption, more marked on the chest and abdomen, which may be simply a slight hyperemia of the skin, or it may take the form of irregular macules without elevation or induration — syphilitic roseola or macular syphilids. With this there is a painless enlargement of the lymph-nodes throughout the entire body. These are appreciated best in the cervical region, both the anterior and pos- terior chains, in the epitrochlear regions, in the axilhe and groins. As the initial eruption fades other cutaneous lesions appear, generally in the form of papules — papular syj>hilide. These, as a rule, are small elevated nodules of a brownish-red or copper color, and are distinctly indurated. They appear first on the abdomen, chest, and back; later on the arms and thighs; at a still later period on the forearms, face, and legs; and finally, on the palms and soles. With these early secondary cutaneous lesions there is often an increase in the headache and malaise; the mucous membrane of the mouth and pharynx presents superficial ulcerative lesions or mucous patches, which are most frequently located on the lips and cheeks, near the angles of the mouth, on the sides of the tongue, on the tonsils and SYPHILIS 63 pharynx. There is an increased flow of saliva, the mouth is sore, and swallowing may be painful. Scabs appear on the scalp, the hair falls out, the eyebrows and beard may become markedly thin, and in places complete alopecia may be present. These symptoms persist for a variable period in untreated cases, but they may disappear spontan- eously in a short time. In certain cases the symptoms are so mild as to be overlooked. At a later period recurrent eruptions appear on the skin, generally less symmetric, and often limited to small areas. These may be papular (large and small), pustular, squamous, or pustulocriis- taceous. In certain moist localities, as about the anus, in the axilhe, or beneath a pendulous breast, large flat raw lesions may appear, \ J c i? '* ^H ^^^apP^^ ^B W^ V i^^pm*^*" ■ . * r^L -Jr^ w Fig. 8. — Chancre of the penis. which furnish an acrid secretion. These are spoken of as condylomata or mucous tubercles. Papillomata may also appear in these situations, but are not to be regarded as truly syphilitic lesions, as they occur under other conditions. If the patient has been under intelligent treatment during the first two years after his inoculation, the symptoms of the disease gradually disappear, and he may be completely restored to health. Tertiary Period. — In a fair number of cases, however, chiefly those who have not been subjected to continuous treatment for two years, lesions appear later in life which are called gummata. These consist of masses of round and epithelioid cells, often forming large 04 CHRONIC INFECTIOUS SURGICAL DISEASES tumors which present a gray or yellowish color, are poorly nourished, and are prone to break down and present caseous or necrotic changes. These lesions may occur in any organ or tissue of the body and give rise to a variety of symptoms. When they occur in the skin they pre- sent lesions spoken of as tubercular, pustulocrustaceous, rupial, ulcera- tive, and serpiginous syphilides. In the subcutaneous tissues they give Fig. 9. — Gumma of the knee. rise to gummatous ulcerations. On the mucous membranes, especially that of the pharynx, gummata grow rapidly and painlessly, ulcerate, and cause great losses of tissue in a comparatively short period of time. The syphilitic virus also produces marked changes in the blood- vessels, which are observed chiefly in the smaller arteries, and result SYPHILIS 65 in a slowly progressive narrowing of their lumen, syphilitic endarteritis. This, by diminishing the blood supply to a part, results in various degenerative changes, which occur most frequently in the tertiary period of the disease, and give rise to a variety of lesions, chief among which may be mentioned aneurism, cerebral hemorrhage, thrombosis, chronic interstitial changes in certain organs, and interference with the blood-making function. Locomotor ataxia, paresis, and other disturb- ances of the central nervous system are regarded by most authorities as late effects of the syphilitic poison, and are spoken of as para- syphilitic affections. The tertiary syphilitic manifestations in the different organs of the body will be described later. Diagnosis. — The diagnosis of syphilis, in the great majority of instances, is easily made from the history and the results of a careful physical examination. In certain rare instances great difficulty may be encountered. In these cases the demonstration of the spirochete in the lesions is of great value. The Wassermann blood reaction is of essential service in making a diagnosis or rather establishing whether or not the individual is a syphilitic. Treatment. — Until the diagnosis is established, no treatment other than that addressed to the initial lesion should be given. The habit of giving mercury in doubtful cases to prevent the possible appearance of cutaneous and other lesions is to be condemned, as it may prevent the possibility of ever arriving at a correct diagnosis, and renders the life of the individual miserable from doubt and syphilophobia. In the early or secondary stage of the disease the chief reliance must be placed on the judicious administration of mercury and the arsenical preparation salvarsan or " 606," formulated by Ehrlich. Sal- varsan may be used in several intravenous injections but must be followed by the old time mercury, potassium iodide treatment. Neo- salvarsan a subsequent preparation of arsenic is also used intravenously with success. After one or more injections of salvarsan have been administered and a negative Wassermann obtained, it is desirable to employ mercury in some form. This may be accomplished by the internal, the external, or by the subcutaneous use of the drug. Internally the protiodide of mercury, preferably combined with iron to combat the always present syphilitic anemia, is the most useful form of drug. At first from 1 to 2 grains of the drug should be administered daily in divided doses, taken immediately after meals. As soon as the effects of the drug are noticeable, the dose should be diminished and kept at a point where the symptoms are controlled without producing salivation, diarrhea, or other unpleasant effects. The amount of mercury necessary to control the symptoms of the disease is exceedingly variable. Some patients will keep free from symptoms by \ grain daily, while others require from 2 to 3 grains. When the dose is finally adjusted to the needs of the patient, it should be continued for two years. After this the treatment should be taken every second month for six months, after which a period of observation 5 66 CHRONIC INFECTIOUS SURGICAL DISEASES for six months should be insisted upon without treatment, at the end of which, if the patient has remained free from all symptoms of the disease, he may be pronounced well. On account of the ease of admin- istration of mercury in this form, this will probably remain the most popular method of treatment for syphilis, in spite of the fact that the methods of inunction and injection are less liable to disturb digestion. Mercury may also be administered by the inunction of mercurial oint- ment (30-60 grains once daily), by the vapor bath, or by means of hypodermic injections. If the inunction method be employed, the ointment should be rubbed in the non-hairy portion of the skin, and a new location should be chosen each day until all of the available skin has been covered. The inunction method is considered by many more efficacious than the method of ingestion, but is less popular on account of the disagreeable features attending its application. Hypodermic or intramuscular injection, while at all times slightly painful, is one of the surest, swiftest, and safest methods of treatment of syphilis. The salt of mercury most generally employed in this way is the salicylate, which is used in the following form. Salicylate of mercury, 3 (gr. xlviij) Alboline or oil of vaseline, 30 I (5J) Inject 5 to 10 cgm. (9 to 16 minims) once or twice a week. Fournier expresses a preference for "gray oil" of the following composition : Purified mercury, • 20 parts Vaseline, 10 parts Oil of vaseline, 20 parts Dose.- — Three drops at first, the dosage being increased up to seven, eight, or ten drops once a week. For the tertiary gummatous lesions the treatment should be salvar- san, mercury, and potassium iodide, the two former to combat any virus which may still remain in the body, the latter to promote absorp- tion of the gummatous material. These latter drugs may be given in combination by the "mixed treatment" or separately, mercury being given until the constitutional effects or the drugs are beginning to be manifest, followed by potassium iodide in doses ranging from 5 to 100 grains three times a day. Treatment has no effect on the vascular lesions of the disease or the degenerative changes which result from them. The parasyphilitic lesions of the central nervous system are often much benefited and improved by salvarsan. Congenital Syphilis. — A child may acquire syphilis from the mother before birth, and authorities hold that the mother of a syphilitic child is always syphilitic. It is generally recognized that mothers are immune to a secondary infection, as evidenced by the fact spoken of as Colles' law, that a nursing mother never acquires a nipple chancre from her syphilitic offspring. Pregnancy occurring in a woman during the early secondary stage SYPHILIS 67 of an untreated syphilis generally results in abortion. If the woman is well under the influence of treatment, or if conception occurs at a later period, premature birth of a dead fetus is to be ex- pected. If the virulence of her infection is reduced still further by treatment or time, a living child will be born presenting unmis- takable signs of congenital syphilis. If the virus is attenuated still further, an apparently healthy child may be born, which may later in life present the evidences of syphilis, or the child may be free from disease. It is exceedingly rare for a syphilitic child to be born of a syphilitic mother who has been under mercurial treatment for two or more years, or of a mother four years after the date of her inoculation Fig. 10. — Craniotabes of syphilitic origin. with or without treatment. Parents frequently beget healthy children while they still present on their bodies the evidences of tertiary syphilis. It is probably impossible for a syphilitic father to transmit syphilis to his child through a healthy mother. Symptoms. — With the exception of the initial lesion, all of the symptoms of acquired syphilis may occur in the congenital form of the disease. Syphilitic children are generally premature, are small, puny, and often deformed. The face is pinched and the skin wrinkled, giving the appearance spoken of as the "old-man countenance." A macular eruption is frequently present at birth over the trunk, and mucous patches frequently are found about the mouth and anus. The child is irritable, suffers from snuffles and digestive disturbances, 68 CHRONIC INFECTIOUS SURGICAL DISEASES and rarely thrives. Visceral lesions may develop, generally gummatous in character, and early death is the rule. If the infection is less virulent, the appearance of the child at birth may be normal; digestive and nutritive disturbances, however, occur; and as the child grows, symptoms of rickets, bone, and joint disease develop, with keratitis, cutaneous lesions, and glandular enlargements. The two upper central incisors of the permanent teeth are often notched and narrowed (Hutchinson teeth), and other deformities of the bony skeleton may be present, as a thinning of the bones of the skull (craniotabes) (Fig. 10) and enlargement of the epiphyses (syphilitic osteochondritis). Treatment. — Congenital syphilis is treated best by the application of mercurial ointment, half strength, or of the oleate of mercury, 5 per cent., to the body of the child by means of a flannel bandage, which should be worn each night. Good food, tonics, iron, and cod-liver oil are useful at a later period. ACTINOMYCOSIS. Actinomycosis is a chronic, infectious disease, common to man and many of the domestic animals, caused by Streptothri.v actinomyces, or the ray fungus. Etiology. — Actinomycosis is a widespread infection among cattle, in which it is known chiefly as "lumpy jaw." The organism probably belongs to the streptothrix group of bacteria. In the infected tissue, the contents of abscess-cavities, and the discharge from fistulous tracts the actinomyces may be found in the form of small yellowish, more or less opaque granules, varying in size from 0.15 to 0.75 mm., although larger granules often are seen. In their earliest stage the granules are usually grayish white and are easily broken up, the consistency being that of a soft jelly. As the granule grows older, it becomes more opaque and yellow, and finally it may become impregnated with calcium salts. In the earlier stages the granules are made up of fine threads, which later become thicker, and at their ends present bulbous swellings. Gradually the threads become more compact and intricate in their arrangement, and the bulbous swellings become arranged radially about the periphery of the granule. The mycelium usually appears as a bacillus from 3 to 6^ in length, arranged in threads having many branches. The actinomyces stain readily with the ordinary basic anilin dyes. They are not decolorized by Gram's method. The bulbous swellings, on the other hand, stain only with acid dyes. The organism is a facultative anaerobe and grows upon most of the artificial media. The most favorable temperature for its growth is from 33° to 37° C. It is conceded that spore-formation occurs, the spores being much more resistant to injurious agents than is the mycelium. The actino- myces do not appear to manufacture any active toxin. Attempts at ACTINOMYCOSIS 69 artificial production of the disease have not been satisfactory. The great carriers of the actinomycotic excitant are the different forms of cereal, especially barley, and it is mainly through their agency that man and the domestic animals become infected. Men are infected more frequently than women. Of 357 cases of human actinomycosis collected by Hutyra, one-third occurred in the third decade. Four chief avenues of infection have been distinguished: First, through the mouth and pharynx, particularly carious teeth; second, through the respiratory tract; third, through the gastro-intestinal tract; fourth, through the skin, wounds, etc. In a certain number of cases no portal of entry can be made out. Pathologic Anatomy. — The lesions at the outset may be insignificant. Microscopic examination of an actinomycotic focus shows a central portion containing the fungus. In addition there are more or less debris and products of degeneration. Around this portion is a zone of small, round, and epithelioid cells. The outermost portions of the actinomycotic focus are characterized by more or less extensive round-cell infiltration. Giant cells are sometimes present. The pro- liferation of cells may become so extensive that a definite tumor-like mass is produced. Suppuration sometimes occurs. The tendency to the formation of fistulous tracts is characteristic, the discharge from these fistulse sometimes being serous, sometimes purulent. The dis- charged material usually contains the actinomycotic granules. The lesions extend rather by continuity than by metastases. Poncet and Berard proposed the following division of actinomycotic infections: First, cervicofacial; second, thoracic; third, abdominal; fourth, cutaneous. Foci in the spinal column, genito-urinary tract, brain, special organs of sense, etc., are regarded as complications. Statistics show that about 55 per cent, of the cases belong to the first group; about 20 per cent, to the thoracic and pulmonary group; and about 20 per cent, to the abdominal type; 5 per cent, covering the remaining forms. It is stated that lymph nodes do not become involved except by local extension through the tissues. This suggests that the parasite is carried by the blood stream rather than lymph vessels. Symptoms. — Actinomycosis, with rare exceptions, is a chronic disease, lasting for months or years. Four clinical forms are described: Face and Neck. — The initial lesion often begins around a carious tooth. The patient comes under observation with a swelling of one side of the face or with an enlargement of the jaw, which may simulate sarcoma (Fig. 11). The lesion is seen best on the outer side of the jaw in the form of a swelling, with one or more fistulous tracts discharging material which often contains the characteristic sulphur- like granules. In the chronic forms pain is not frequently com- plained of, except perhaps on pressure. Fever is generally absent and the general health remains satisfactory. If not checked, the process may extend to the neck, along the pharynx, and finally involve the vertebrae or the thoracic organs (Fig. 12). Amyloid degeneration of 70 CHRONIC INFECTIOUS SURGICAL DISEASES the viscera is sometimes seen. In the acute forms fever is present and the symptoms are those of phlegmon. The tongue is rarely involved. Thorax. — Involvement of the thoracic organs is generally secondary to lesions on the face and neck, but the lungs may be the primary seat of the infection. In this form we have a chronic infectious disease of the lungs— cough, fever, emaciation, and mucopurulent discharge. Hodenpyl recognized three types: First, lesions of chronic bronchitis; second, miliary actinomyces, the lesions of which closely resemble A Fig. 11. — Actinomycosis of the cheek. (Ulich.) those of miliary tuberculosis; third, cases in which we have broncho- pneumonia, interstitial changes, and abscess formation. Clinically the disease resembles certain forms of pulmonary tuberculosis. The diagnosis is made by finding the actinomyces. Abdominal Organs. — In this form the gastro-intestinal tract is primarily involved. There is no organism which may cause so exten- sive destruction of the abdominal viscera as actinomyces. Adhesions and abscesses are conspicuous features of the lesions. The actinomyces gain access to the stomach with food, either ACTINOMYCOSIS 71 animal or vegetable, most commonly the latter. Neither the gastric juice nor the bile appears to have any very decidedly harmful effect upon the fungus. Once having penetrated the mucosa, two modes of progression are possible: first, a superficial involvement of the mucosa; second, a penetration into the deeper structures without leaving behind any demonstrable defect in the mucosa. Intestinal actinomycosis usually appears first as a small nodule in the submucosa, w r hich undergoes degeneration at its centre and presently gives rise to a small ulcer. In certain instances the ulcers heal, leaving irregular pigmented scars. Among the secondary lesions of abdominal actinomycosis those of the liver are the most frequent. From 50 to 60 per cent, of the abdominal cases originate in the cecum and appendix; less frequently the disease starts in the rectum, stomach, or small intestine. Fig. 12. — Actinomycosis of the neck. (Lexer.) In many cases the onset is quite sudden — catarrhal disturbance of the intestine, diarrhea, vomiting, or constipation. In other cases the symptoms simulate those of recurring appendicitis. The initial symptoms may last for weeks or months. The second period of the disease is characterized by tumor formation, which is generally in the right iliac or umbilical region. The tumor outline is usually in- definite and irregular. Pain is common. Later, softening of the in- filtrated portions takes place, leading to fistulous formation, and the surrounding skin assumes a bluish-violet tint, which changes to a slate color from centre toward the periphery. According to some observers this appearance is sufficiently characteristic to excite sus- picion of actinomycosis. Spontaneous recovery is possible. The prog- nosis is variable; it is the best in those cases which are amenable to 72 CHRONIC INFECTIOUS SURGICAL DISEASES surgical treatment, and it is for this reason that the prognosis is more favorable in abdominal than in thoracic cases. Skin and Brain. — Actinomycosis of these tissues is rare. In the skin the lesion simulates tuberculosis. The cerebral lesions are gen- erally postmortem findings. Treatment. — This is largely surgical. If the foci of infection can be completely removed, recovery may be expected. In the majority of instances this is not possible, and partial removal with the admin- istration of large doses of potassium iodide, or the salts of copper, con- stitutes the best treatment. The various forms of radiant energy may be employed. Fig. 13.— BLASTOMYCOSIS. Blastomycosis {Oidiomycosis) is a localized inflammation affecting the skin (blastomycetic dermatitis) and deeper tissues, which is caused by the parasite yeast organisms, Blastomycetes or Oidii. These occur as rounded, double-contoured bodies measuring 10 to 2(V in diameter, which reproduce by budding and contain various rounded, refractile or granular structures (Fig. 13). They are found in the diseased tissues and frequently within giant cells; are readily cultivated on artificial media, and can be successfully inoculated into animals. Clinically the disease may be confused with syphilis, lupus vulgaris, lupus verrucosus, or epithelioma. The diagnosis may always be made by microscopic examination of smears and tissue. BLASTOMYCOSIS 73 The process is found most commonly on the skin of the hands and face, particularly about the orbit. Though generally local, generaliza- tion may take place, causing involvement of the lungs, hones, muscles, spleen, or kidneys. Though the skin is usually the scat of the primary infection, the viscera may be the structures first involved. Clinically the disease starts as a papule, developing into an ulcer, which may become quite extensive. It extends laterally by the for- mation of minute, dermal, and subdermal abscesses. A superficial crust covers a red granulating mass, which is verrucous, with sharp, elevated borders, and exudes a seropurulent secretion (Fig. 14). Microscopically there is extensive tissue hyperplasia, containing giant cells, small abscesses, detritus, and the organisms. The sur- r * ! .a'. 1 7. ■» • • ft* ' R' X<£. W'Jk*^ V*- M % V*' i M K % f Fig. 14. — Cutaneous blastomycosis. (Hyde.) rounding tissue shows chronic inflammatory changes with the presence of giant and mast cells. When limited to the skin this disease, though of an obstinate nature, is not fatal. Systemic infection, however, generally results in death. Treatment. — Treatment consists of curetting or, preferably, complete extirpation. Improvement and cure have occasionally been obtained by the internal administration of large doses of potassium or sodium iodide and the local application of antiparasitic solutions. Bevan has advo- cated copper sulphate in dosage of \ grain t. i. d., increasing it to \ grain t. i. d., and externally a 1 per cent, copper sulphate wash. CHAPTER V. TUMORS. The word tumor is often used by the clinician in a general and indefinite way to designate any abnormal swelling of circumscribed extent, without reference to the cause or precise character of the lesion. Etymology justifies this use; but custom has narrowed its application. It is therefore proper to restrict the meaning of the term, so that by its use we may denote any circumscribed new growth of tissue, derived from some pre-existing normal body tissue by pro- liferation of the constituent cells, which shows greater or less departure from the typical structure and functions of the parent tissue, which serves no useful purpose, and which generally is not restrained within definite growth limits. Tumors are then independent, or as Thoma characterizes them, "autonomous" new growths. They may arise in any tissue, the cells of which are capable of reproduction and the smaller bloodvessels of which are competent to nourish the newly developing structure. The process of cell division and of development of new bloodvessels are in general similar to those of normal tissue growth, regeneration, and repair. The finer details of nuclear divi- sion by karyomitosis are, however, frequently atypical, and the cellu- lar growth often shows an exuberant development well expressed by the word "lawless." The cells composing tumor growths are largely subject to heredity, and hence the histology of a given tumor usually enables us to determine its tissue paternity. Etiology. — The etiology of tumors is a very complex and difficult subject, which can be only briefly touched upon here in its more important aspects. Having a bearing upon the occurrence of tumors, the following are distinctly recognized : Age. — Though tumors are most frequent in adult and advanced life, there is a tendency for those of the connective-tissue type to occur somewhat earlier than those of the epithelial type. Sex. — While, in general, malignant tumors are about twice as fre- quent in females as in males, malignant tumors of the stomach, tongue, and lips are more common in males. On the other hand, tumors of the breasts and reproductive organs are far more common in females. Race. — While carcinoma is common in the white race — especially in the female breast and uterus, it is a striking fact that this form of tumor is exceedingly rare in the negro race — where tumor formation in these organs is far more frequent in the form of fibromata. INNOCENCE AND MALIGNANCY IN TUMORS 75 Local Predisposing Factors in the Development of Tumors. — Though the part played by local injuries in the formation of tumors is a matter not clearly understood, it has frequently been observed that while bruises or contusions — especially those involving the bones — are sometimes followed by the formation of malignant tumors of con- nective-tissue type — sarcoma, osteosarcoma, etc. — repeated injury or long-continued irritation is more liable to be followed by the formation of malignant tumors of the epithelial type. Such an observation is especially applicable in connection with tumors of the sphincters of the body and tumors of the breast and stomach following prolonged inflammation. While Volkmann's theory of the influence of trauma undoubtedly represents one of the -factors active in the production of malignant tumors, more stress has recently been placed on Cohnheim's theory advocating the occurrence of tumors as the result of the growth of superfluous or displaced embryonal cells. Ribbert, recognizing the importance of both of these theories, considers another factor essential, viz., the separation of cells from their normal relationships by em- bryonal or postfetal developmental processes, by trauma or inflam- matory processes; the dissociated cells growing independently and in limitless fashion, because the organism has lost control over them. The theories advocating bacteria and other parasites as a cause have never received very strong support, though many observers have been impressed with the occurrence in some tumors of protozoa-like bodies. The striking analogy which exists between the clinical course of cancer and some of the chronic infectious diseases renders this theory at least reasonable. The theory of the communicability of cancer, still to be proved, finds some of its strongest advocates among the supporters of this origin of cancer. While the communicability of cancer has never been proved in man, some of the most interesting and important of the modern research work on cancer has shown that it is possible to transplant pieces of cancer tissue from one animal to another of the same species and continue this process through many generations of tumor growth. Ehrlich has even secured active immunity against cancer in mice by injection of the living cells of slightly virulent strains of mouse carcinoma. Innocence and Malignancy in Tumors.— There is no sharp dividing line between innocence and malignancy in tumors, for while such tumors as fibromata are always clearly benign, and small round- celled sarcomata always clearly malignant, there are tumors belonging to the same connective-tissue type group which occupy an interme- diate position. Such, for example, are the so-called endotheliomata, gliomata, and giant-cell sarcomata. Furthermore, there is some evidence that a benign adenoma, when existing in such an organ as the female breast, may be excited to malignancy through the agency of a concurrent inflammatory process; and that special potentialities 76 TUMORS of malignancy may exist in some benign tumors merely in relation to their anatomic location is evidenced by the frequency with which some papillomata of the larynx, and urinary bladder, and adenomata of the uterus and large intestine assume malignant character. Malignancy, then, being a relative term, and its signs developing irregularly with the growth of the tumor, reliance for its diagnosis must be placed, not upon one attribute of the tumor, but upon several taken in conjunction with each other. 1 Such attributes are as follows: Gross or Clinical: Rapidity of growth. Invasion of adjacent tissues by eccentric or peripheral growth or infiltration. The tendency to local recurrence after removal. The formation of metastases. The tendency to produce cachexia. Microscopical: Abundance of mitoses, especially of abnormal types. Evidences of "lawlessness" and variation in size of cells, and degree of departure from normal types. Poor structure of bloodvessel walls and tendency to hemorrhage. Relatively larger size of nucleus. Tendency to degeneration. While it is an obvious corollary that conditions opposite to those stated in the previous list point to innocence in tumors, there are a few exceptions which it is well to bear in mind. For example, while degeneration is most common in tissues whose rapidity of growth outruns its blood supply, and in tissues which are so lawless and unstable as to have little vital resistance, nevertheless it is not uncommon to find many types of degeneration in even the most benign tumors. Such, for example, are hyaline, amyloid, fatty, album- inous, calcareous, or mucoid degenerations. Furthermore, while most benign tumors are circumscribed, some, such as a few lipomata, may be diffuse; even benign tumors may recur if not completely removed; and some benign tumors — angio- mata— may be largely composed of bloodvessels, many of which have poorly formed walls, with some tendency to hemorrhage. Treatment. — The treatment, in general, of all operable tumors, is essentially surgical, the character of the operation being dependent upon the character and location of the tumor. (See chapters on Special and Regional Surgery.) While a few non-operative procedures for the treatment of tumors — of which the use of caustics, the various forms of radiant energy, and Coley's serum are examples — are known, these methods have their most frequent applicability in instances 1 According to the conception of malignancy here used, this term would not apply to the effect of pressure of a tumor on a neighboring vital organ or interference with its function through pressure or displacement. SPECIAL VARIETIES OF TUMORS 77 where consent for operation cannot be obtained or instances of inoper- able malignant tumors. While there are occasional exceptions in the treatment of some cysts, the cardinal rule of procedure in the case of all operable tumors is removal in their entirety, as even the most benign tumors will return if only partially removed, and innocent cysts will often be reformed if a portion of the cyst wall be allowed to remain. Classification. — The pathologic classification of tumors is most conveniently based upon their anatomic structure. They may be divided into the following groups: Connective-tissue Type. Fibroma, . Endothelioma, Lipoma, Glioma, Myxoma, * . / Hemangioma, Chondroma, ngiomaj Ly m pi ian g} oma) Osteoma, yr r J Leiomyoma, Myeloma, \oma j Rhabdomyoma, Sarcoma, Neuroma. Epithelial-tissue Type. Papilloma, Carcinoma, Adenoma, Epithelioma. Mixed Type. Teratoma . Special Tumor Types. Chorion-epithelioma or deciduoma, Hypernephroma, Psammoma. SPECIAL VARIETIES OF TUMORS. Fibroma. — The gross and microscopic features of fibroma resemble those of connective tissue. They may be hard, fibroma durum, or they may be soft, fibroma molle. Generally they are circumscribed masses, frequently encapsulated. They vary in shape, sometimes growing as papillomatous masses, or as polypi seen in the nose, or they may be diffuse. Many of these growths, especially the firmer ones, present a white surface in which the fibrous strands may be seen interlacing in various directions. Fibromata may occur anywhere in the body, but are found especially in the skin, periosteum, fascia, uterus, and mammary gland. The firm fibromata are usually oval or globular, smooth, movable, very hard, generally single, and painless unless attached to a nerve. The softer forms are smooth, globular, elastic, soft, and painless. Tumors of this class are usually of slow growth, and do not give rise to true metastasis. 78 TUMORS Microscopically, fibromata consist of connective tissue showing variable proportions of cellular elements. The hard varieties show few cells and bloodvessels; the softer ones, on the contrary, are more cellular, and generally have a richer blood supply. They often con- tain elastic tissue. Mucoid, myxomatous, and fatty changes are com- mon. Keloid is a form of fibroma which develops in scar tissue after injury or operation. Lipoma. — The structure of tumors of this class is like that of ordi- nary adipose tissue. They are often found in the subcutaneous tissue about the neck, shoulders, axillae, and groins. Less frequently they are found in the kidneys, intestine, and other viscera. They are of slow growth, and sometimes follow injury. They are benign, but Fig. 15. — Intracanalicular fibroma of breast. occasionally cause disturbances by pressure. They form circumscribed and encapsulated, lobulated, pseudo-fluctuating, painless, soft elastic tumors, generally single, but occasionally multiple, and grow slowly (Fig. 16). A diffuse form is known, occurring most frequently in the neck. A dimpling of the skin is often evident when these tumors are pinched up between the thumb and finger. Myxoma. — Tumors of this class are closely related to the fibromata. A pure myxoma is unknown. Myxomata are rather soft, gelatinous tumors, of various shapes and size. The outlines are well defined; and when growing from mucous membranes they form polypi. They consist of stellate and spindle-shaped connective-tissue cells; and the tissue spaces are filled with a substance resembling mucin. Their appearance is like that of certain edematous fibromata. Myxomata SPECIAL VARIETIES OF TUMORS 79 have been found in the skin, breast, brain, and spinal cord. Most of the soft nasal polypi belong to this class. As with fibromata, growth is usually slow. Chondroma. — This group includes tumors made up of hyaline or fibrocartilage. On section they have a cartilaginous appearance and Fig. 16. — Lipoma, showing characteristic lobular appearance. Fig. 17. — Chondroma. are often encapsulated. Areas of ossification or mucoid degeneration are common. They may arise from tissues which normally contain cartilage, but they are often found where none normally exists, as in Fig. 18. — Cancellous osteomas springing from the diploe. (Musee Dupuytren.) the testicles, bone, parotid glands, mammse, etc. Multiple chondro- mata are occasionally seen on the hands and feet (Fig. 17). Growth is slow and they are benign. Very rarely metastasis occurs. Mixed forms of cartilaginous tumors are common; most of those in the parotid and testicles belong to this class. so TUMORS Osteoma. - -An osteoma is a new growth composed of bony tissue. Two varieties are recognised: the spongy or cancellous and the com- pact. The spongy osteoma is most frequently found at the ends of the long bones of the limbs, or growing from the cranium (Fig. 18). It grows very slowly, and rarely causes any discomfort unless it presses upon a nerve trunk or important organ. The compact osteoma usually grows from the bones of the skull. Tt is generally sessile and solitary, and may grow into the interior of the skull, into frontal sinus, or into the cavity of the orbit or nose. Exostoses are bony tumors growing upon the surface of bones. These formations some- times occur in muscles and ten- dons, especially at their points of attachment to the skeleton. The name odontoma is applied to an osseous growth in connec- tion with teeth. Myeloma. — Occupying a posi- tion intermediary between the osteomata and osteosarcomata are those bone tumors known as myelomata which are considered by Bland-Sutton to form a class distinct from both. They are composed of tissue resembling the red marrow of bone and differ from sarcomata in not being malignant. They occur most frequently in the cancellous tissues at the ends of the long bones. The cut surface of the tumor usually presents a deep red or maroon color. The tumor grows slowly, expands the bone, and thins the osseous cap- sule while expanding it until the bony shell is so thin that it crepi- tates when pressed by the finger (Fig. 19). Microscopically myelo- mata abound in large multinuclear cells (giant cells) imbedded in round or spindle cells. If the giant cells do not greatly predomi- nate, but occur with round or spindle cells in nearly equal pro- portions, the tumor becomes more nearly allied to the mixed-cell sarcomata. To the myeloid type of tumor, abounding in giant cells, which occurs in connection with the gums, the name epulis is applied (Fig. 20). The growth of these tumors is slow. Fig. 19. — Lower end of the femur in sec- tion to show a myeloma. From a girl seven- teen years old; she was known to be alive and well five years after amputation through the middle of the thigh. SPECIAL VARIETIES OF TUMORS M Sarcoma. — Tumors of this class arc malignant in nature and are composed of miniature mesoblastic or embryonic connective tissue, Epulis. Myeloma of jaw. Fig. 21. — Sarcoma of too. in which cells predominate over intercellular stroma. They present divers characters structurally and clinically, but have the following in common : 6 82 TUMORS Each cell is surrounded by a varied amount of intercellular sub- stance which has no definite arrangement; the bloodvessels have very thin walls, and are often merely spaces bounded by the cells themselves, hence, the frequency with which hemorrhages occur. Dissemination usually takes place by the bloodvessels. Sarcomata occur most frequently in youth and early middle life. Their origin may some- times be found to be associated with trauma, and any region of the body may be involved. The most common locations are the subcuta- neous areolar tissue, fascia, bones, periosteum, kidney, meninges, lungs, liver, and alimentary canal. Sarcomata are classified most conveniently according to the prevailing types of cell present; some species being subdivided into two or more varieties and some consisting of mixed forms. Round-celled Sarcoma. — This group consists of the small and large round-cell sarcomata, as well as that known as lymphosarcoma and gliosarcoma. They are among the most malignant of all tumors. Their consist- ency is usually soft, they are vascular, and often grow to a large size with a great tendency to disseminate. The small-celled variety consists of small round cells with very little cytoplasm and intercellular stroma; so little in fact as to be diffi- cult to demonstrate. The bloodvessels are thin-walled channels occurring between the cells of the tumor (Fig. 22.) In the large round-cell variety the cells are larger but variable in size, the nuclei are large and contain prominent nucleoli, the cytoplasm and intercellular substance are more abundant, and the tumor is somewhat firmer than the small round-cell tumor. Lymphosarcomata are excessively malignant, arise from lymphoid tissue, and consist of small round cells resembling lymphoid cells contained in a delicate reticulum. Gliosarcomata occur most frequently in the brain and retina, and have a matrix like that of the neuroglia of nerve centres. Fig. 22. — Sarcoma of bone. SPECIAL VARIETIES OF TUMORS 83 Spindle-cell Sarcoma. — This group, consisting of the small and large spindle-cell sarcomata, is of common occurrence. They frequently Fig. -•'•>. — Spindle-cell sarcoma of chest Fig. 24. — Melanosarcoma of the heel. are found in the periosteum, subcutaneous tissue, muscle, uterus, and secreting glands (Fig. 23). On section they have a pinkish-white 84 TUMORS color, the large cell type being soft and rapid growing, while the small cell type is slower in growth and moderately firm. In both the cells are spindle-shaped, often arranged in fascicles which surround the bloodvessels, with very little intercellular substance. In the large spindle form the cells frequently contain several nuclei. Closely allied to these two groups in the morphology of the cells are the melanosarcomata, which may be composed of round, spindle, or polyhedral cells. They arise in the choroid and in the skin, espe- cially from pigmented moles. They receive their name from the fact that particles of brown or black pigment occur in the cells or intercellular substance. These tumors are very malignant, and have a marked tendency to form metastases, which are also pig- mented (Fig. 24). Giant-celled Sarcoma. — Giant-celled sarcomata are tumors closely resembling the myelomata (already described), but containing sphe- roidal or fusiform cells in excess of giant cells, and having well-marked malignancy. Some originate in the marrow, are soft and very vascular, and prone to form metastases. Others originate in the periosteum, are firmer, and grow up by a new formation of bone tissue as an osteosarcoma. In the mixed forms of sarcoma the types of cells already described are found associated with a new growth of bone (osteosarcoma), blood- vessels (angiosarcoma), glands (adenosarcoma), connective tissue, cartilage, etc Endothelioma. — Many pathologists cling to this term, believing that there is a place for it in tumor morphology. Others believe that a par- ticular tumor is either a carcinoma or a sarcoma and that it has not originated from so-called endothelium which preserves an individuality of cell structure. In the writer's opinion these neoplasms are in the majority of instances epithelial growths. Glioma.— Under this heading are grouped certain tumors which originate either from the neuroglia of the brain and cord or from the cells lining their cavities. It is only rarely that they take their origin in the retina. They do not often gain great size and may be either hard or soft. In color they resemble that of the tissue in which they are found. Histologic studies show that they are composed of neuroglia tissue often associated with true nerve tissue, such as ganglion cells and nerve fibres. Evidences of old and recent hemorrhage are com- mon. Growth may be slow or rapid, involving the brain and cord, but not their membranes. Gliomata of the retina are generally malignant. Angioma. Tumors chiefly composed of vascular elements are grouped under this heading; those of bloodvessel origin, as heman- gioma, and those of lymph vessel source, as lymphangioma. Hemangioma. — Several varieties of hemangioma are recognized. In the case of the "port wine" skin discolorations, birth marks, or nevi, it is doubtful whether there is any formation of new bloodvessels or SPECIAL VARIETIES OF TUMORS 85 not; some believe that the growth is due to dilatation or hypertrophy of bloodvessels originally present. There is another variety of angioma which consists of communicating blood spaces bounded by endothelium and connective-tissue walls. These are known as cavernous angiomata (Fig. 25). The hemangiomata are small or large, of a bluish, purple, or reddish color, and sometimes showing pulsations. They bleed easily. The diffuse simple angiomata, angioma telangiectoides, are usually found in the skin, especially in the region of the neck and head. They are mostly of congenital origin. The cavernous angiomata are, on the other hand, generally found in the liver. Lymphangioma. — Lymphangiomata consist of growths fo'rmed either of dilated or newly developed lymph vessels. Apart from differences as to their contents, they have essentially the same structural features as the angiomata of bloodvessel origin. Thus we have lymphatic nevi, lymphatic telangiectasis, and cavernous lymphan- gioma; whereas those which contain chyle are termed chylangiomata. Myoma. — Tumors of this group consist either of striped (rhabdo- myoma) or unstriped (leiomyoma) muscle tissue. Rhabdomyoma. — The rhabdomyo- mata are rare, and have most often been found in connection with the genito-urinary tract, especially the kidneys. They appear generally in childhood, and are sometimes asso- ciated with sarcomatous tissue. The size of these growths is small. The characteristic histologic features con- sist in the presence of striated muscle tissue, of smaller size than normal and rather irregularly arranged. Leiomyoma. — The leiomyomata are known best under the name " uterine fibroids." Many of them are of very large size and they may be single or multiple. They are usually firm, nodular, and of whitish or pinkish color. A variable amount of fibrous tissue is generally present in them. The uterus, especially after puberty, is their chief point of origin; less frequently they occur in the gastro-intestinal and genito-urinary tracts, in the skin, and larynx. While uterine leiomyomata may occasion neither inconvenience nor suffering, they frequently give rise to profuse hemorrhage, and they Fig. 25. — Angioma of hand. 86 TUMORS may cause serious symptoms by pressing injuriously on the ureters or the intestine, or by complicating pregnancy and parturition. Fig. 26. — Papilloma of the tongue. Microscopically leiomyomata consist of smooth spindle-shaped muscle fibres collected into bundles irregularly arranged in a con- nective-tissue stroma. Various degenerations are common, such as cyst formation, gangrene, and calcification. Sarcomatous meta- plasia is sometimes observed. Neuroma. — In the strict sense, a neuroma is formed of prolifer- ated nerve elements proper, but the term has been loosely used to include all new growths con- taining nerve cells or nerve fibres in a fibrous matrix, such as am- putation neuromata. True neu- romata are rare, but tumor masses containing fibrous tissue and nerve elements are fairly common. Papilloma. — Papillomata are tumors which project from a cutaneous or mucous surface and consist of a central axis of vascular fibrous tissue, hyper- trophied papilla 3 , with a cover- ing of epithelium, which resembles that of the surface from which the tumor grows. In the papillo- mata of the skin — commonly known as ivarts — the covering consists of epidermis; in those growing from mucous membranes it consists of the surface epithelium. When the surface epithelium Fig. 27. -Multiple papilloma of larynx, (von Bergmann.) SPECIAL VARIETIES OF TUMORS 87 projects as filiform processes, the tumor is called a villous papilloma, the best known example of which is met with in the urinary bladder. Papillomatous growths are also met with in the larynx (Fig. 27), in the ducts of the breast — the so-called duct papilloma — and in the interior of certain cystic tumors of the ovary. Although papillomata are innocent, when subjected to irritation they may become the starting-point of cancer. This tendency is especially well marked in the papillomata of the larynx and urinary bladder, which may develop into papillary epitheliomata; in the duct papillomata of the breast, which may develop into duct carcinomata, and in the case of villous papillomatous growths of the ovary, which may become detached and transplanted to the surface of the peritoneum in large numbers. In old people warty growths of the skin may develop into epitheliomata. Adenoma. — The adenomata are new growths of epithelial type, derived by proliferation of the epithelium of mucous and cutaneous glands or of the more specialized epithelium of certain gland-like organs. The epithelial proliferation is accompanied by a strictly propor- tionate or even an excessive development of a vascular, connective- tissue stroma; and the resulting structure — when the tumor is of glandular origin — is composed of new formed gland spaces, of acinous or tubular type, which are lined by a single or by several superimposed layers of epithelial cells. The epithelial growth shows no tendency to overstep the growth of its supporting stroma, and generally preserves a fairly typical glandular arrangement. There is no invasion of neighboring tissues by peripheral infiltra- tion and no habit of metastasis. Cystic formation is common and quite characteristic of certain adenomata, especially those of the ovary. The adenomata form a very large and variable class. On the one hand, it may be difficult to distinguish a given specimen from a mere regen- eration or hyperplasia of normal gland tissue; on the other hand, it is impossible to distinguish certain adenomata from the malignant car- cinomata. This is especially the case with adenomata of the intestine and uterus. Carcinoma (Cancer). — The carcinomata are malignant tumors com- posed of epithelial cells arranged in the form of columns, atypical acini or alveoli whose walls are formed of connective tissue. The cells, while varying in shape and size, closely resemble in their general characters the epithelial cells of the part from which they spring, and within the alveoli are not separated from each other by stroma, thus differing from the sarcomata. In the fibrous tissue stroma the bloodvessels and lymph vessels ramify. Carcinomata are divided, according to the type of cell of which they are formed, into spheroidal, cylindrical, and squamous forms — members of the last group being always known as epitheliomata, occurring in the skin and squamous-celled mucous membranes. 88 TUMORS The spheroidal cell forms always spring from glandular structures, and are often termed carcinoma simplex. Cylindric carcinomata may spring from any pre-existing cylindric epithelium, but are found most commonly in connection with the gastro-intestinal tract and uterus. While the evidences of malignancy in carcinomata occur according to the general rules already laid down for malignancy in tumors. Fig. 28. — Carcinoma of the female mammary gland with metastases in the axillary lymph glands. special stress is laid upon the fact, that while in the related forms of benign growth, of which papillomata of the skin and rectum may be taken as examples, the growth does not extend below the basement membrane; in the carcinomata of these situations the basement membrane is pierced by the tumor cells. In the cuboidal form the departure from the benign adenoma type is indicated by a piling up of the rows of lining cells, which lose their SPECIAL VARIETIES OF TUMORS 89 direct relationship to the basement membrane and ultimately may form alveoli instead of acini, ceasing to reproduce the glandular type. Carcinomata show the strongest tendency not only to local recur- rence but also to metastasize in distant regions. Extension of the growth is partly by the direct infiltration of neighboring tissues and partly by way of the lymph channels (Fig. 28). Degenerative changes are very common, occurring most frequently as fatty or myxomatous degeneration. From the colloidal form cf degeneration, a type of carcinoma occur- ring most commonly in the stomach and peritoneum, has received its name — colloidal carcinoma. •'-; <* "*£** ; -*•'" ' i'//- I u ■u. *$&':;/ Fig. 29. — Scirrhous carcinoma of breast. Carcinomata produce poisonous products which impair the general health of the individual, resulting in a condition known as cancerous cachexia. The majority of carcinomata (70 per cent.) occur between the ages of forty and seventy. Under fifteen years the disease is scarcely known. Trauma and chronic irritation are important factors favoring carcinomatous development in many cases; but as to the real exciting factors we know very little. Being unable, therefore, to remove the cause, in view of the fact that carcinoma is not only one of the com- monest of surgical diseases, the ability to diagnosticate the condition in its early forms becomes a matter of greatest importance, enabling the removal of the entire process before its extension has made the condition inoperable and its termination fatal. 90 TUMORS Spheroidal-celled Carcinoma. — Spheroidal-celled carcinomata are usually subdivided, according to the relative abundance and density of the fibrous stroma, into ''scirrhous" (Fig. 30) and "medullary" (Fig. 31). No definite line, however, separates these groups. Scirrhous Carcinoma. — Scirrhous carcinoma occurs as a firm, hard, nodular growth, depressed in the centre owing to contraction of the fibrous tissue. This contraction is very characteristic of scirrhus of the breast, where it causes retraction of the nipple and puckering of the skin (Fig. 31). The cut surface is of grayish-white, semitranslucent appearance, like that of an unripe pear. From the central mass stellate processes of new growth may radiate for an indefinite distance into the surrounding tissue (Plate III). Microscopically scirrhous carcinoma consists of collections of spheroidal epithelial cells of various sizes sur- 4 m ^^^^M^3.p^ Fig. 30. — Medullary carcinoma of breast. rounded by an excess of connective-tissue stroma. A single alveolus may consist of many or only two or three cells. The overlying skin may become involved, slough, and an ulcer may result, or the infil- tration may become so dense as to have the consistence of cartilage, forming a "scirrhus en cuirasse." To that form of epithelioma follow- ing an eczematous inflammation of the nipple occurring beneath the inflamed area but having no direct continuity with it the name Paget's disease has been given. Scirrhous carcinoma is most common in women after the age of forty and is of very slow growth, although the lymph nodes in the neighborhood may be early involved by secondary deposits. While the female breast is by far the most common seat of scirrhous carcinoma, it has been found in the uterus, stomach, and esophagus. PLATE III Extensive Carcinoma of Breast. Colored photograph of a fresh specimen. (Lumiere method.) SPECIAL VARIETIES OF TUMORS 91 Eneephahid Carcinoma. — Encephaloid carcinomata occur most commonly in the breast, ovary, stomach, liver, and bladder as soft, elastic, rapidly growing tumors, quickly terminating in ulceration, involvement of neighboring glands, and general dissemination through the body. The stroma is scanty in amount and the spheroidal epithelial cells are contained in large alveoli. Evidences of rapid cell division, degeneration, and hemorrhage are common. Fig. 31. — Atrophic scirrhous carcinoma of the breast, (von Bergmann.) Cylindric-celled Carcinomata. — Cylindric-celled carcinomata consist of cells derived from cylindric or columnar epithelium. They occur most frequently in the stomach, intestines, and uterus, and may occur in the breast as duct cancers. They often begin as papillary out- growths from the mucous membranes, especially when growing in the rectum, where they are frequent. Microscopically, these tumors consist of more or less acinus-like tubular structures composed of several layers of epithelial cells. These acini, which are bound together by a delicate stroma, may, in the later stages, become completely filled with epithelial cells. 92 TUMORS In these tumors there may be seen all gradations of structure be- tween a definite adenoma and a typical carcinoma; hence the name Fig. -i~2. — Epithelioma of the thigh. applied to some of or adenoca re in o m a . Fig. 33. — Epithelioma of sternal region. these intermediary forms of malignant adenoma These gradations are seen especially in growths from the uterine endometrium. In these cases the extension of the growth into the muscular coats is an important indication of malignancy. Epithelioma. — Squamous-celled carcinoma or epithelioma usually occurs at the junction of skin and mucous membrane. It is frequently found on the lower lip, penis, and tongue, less commonly on the gums, palate, tonsils, larynx, pharynx, esophagus, blad- der or uterus, and general cuta- neous surface; rarely on the hands and feet. It has fre- quently been known to follow chronic ulceration and prolonged irritation. It often starts as a SPECIAL VARIETIES OF TUMORS 93 cauliflower mass of warts of horny consistence or, more commonly, as a warty nodule or a fissure. These soon become ulcers, with raised, exerted, sinuous, and indurated edges and a hard, warty, and irregu- lar base which exudes an ichorous fluid. Lymph-node involvement is usually early and extensive. Microscopically j these tumors consist of solid columns of epithelium, which have perforated the basement membrane and have grown into the connective or other underlying tissue. The columns are surrounded by an imperfectly fibrillated stroma or round connective-tissue cell infiltration. The epithelial cells penetrate into the lymph spaces and follow those channels which intercommunicate. Transverse sections Fig. 34. — Basal-celled epithelioma of face. of the epithelial masses show typical epithelial nests. When these cells become compressed they form concentrically arranged masses which undergo keratinization and are known as epithelial pearls. Mitotic figures are usually abundant in the epithelial cells, in many of which the peripheral prickles or spines can be detected. There is a marked tendency to degeneration, causing ulceration and hemor- rhage, and extension occurs by direct infiltration and through the lymphatics (Figs. 32 and 33). Rodent Ulcer. — Rodent ulcer is the least malignant form of epithe- lioma, and arises in the dermis rather than from the surface epithelium ; hence the term basal-celled epithelioma, employed by Krompecher 94 TUMORS (Fig. 33). It usually occurs on the face and is most common on the side of the nose, at the inner angle of the orbit, on the forehead, and the prominence of the malar bone. It is seldom seen in early life, the growth is very slow, and the lymph nodes are rarely affected by second- ary growths. The ulcer is flattened, the edges are raised, indurated, and smooth. Microscopically, it consists of irregular ingrowths from the basal epithelial cells, the new-formed cells being round and small, usually not more than one-third the size of the cells forming an epithelioma. Teratoma. — There is a class of abnormal tissue growth, complex in its nature, varying from the double monster type to the compound tumor of misplaced embryonal tissue, which results from abnormal development of embryonic structures, to which the name teratoma is applied. These tumors are derived from cells capable of giving rise to all the tissues of the individual, and are divided by Adami into twin and filial teratomata. The twin type — of which the fetal inclusion is an example — occurs as an autonomous growth, the product of the continued development within one individual of another individual of the same species. The filial type is due to the segregation and subsequent growth of embryonal cells, which are capable of giving rise to all the different tissue types. As examples of those growing from non-germinal blastomeres may be cited the epignathus, from excess production of growing point cells at the superior pole, and sacral congenital teratomata, formed in a similar way at the inferior pole. A more common form of teratoma is that derived from the germinal blastomeres, to which group of tumors the term embryoma is frequently applied. The germinal blastomeres may become misplaced and then appear as teratomata of the cranium, gill clefts, thoracic cavity, etc.; but even if they remain in the ovary or testicle they may still show a tendency, in postfetal life, to assume active properties of growth and become the testicular and ovarian embryomata, which are by no means uncommon. These tumors, exceedingly complex in their structure, are derived from all three layers (epiblast, mesoblast, and hypoblast), and may contain a great number of different forms of tissue, such as various forms of fibrillar connective tissue, cartilage, bone, teeth, hair, skin, muscle, and glands. While usually benign, these tumors may assume the most extreme malignancy — this character occurring in those tumors in which sar- comatous and carcinomatous elements are present. There is another type of tumor, intermediate between the terato- mata and the simple tumor, which, while not the product of the growth of all three germinal layers, is yet mixed in type. SPECIAL TUMOR TYPES 95 To this group belong various tumors of the kidney, parotid, sub- maxillary gland, vagina, and breast. Such tumors, of which fibro-adenomata, adenocarcinomata, and chondrosarcomata are examples, are considered mixed tumors because more than one type of tissue is present under conditions where these tissues have assumed the characters of the independent growths. SPECIAL TUMOR TYPES. A few tumors exist which are of unusual form and structure, which are not included in any of the common groups of tissue types. These have distinctive names, and include peculiar tumors formed of fetal or placental tissue, called chorion epithelioma or deciduoma; of tissue resembling the adrenals, hypernephroma; peculiar tumors of the dura mater, called psammoma, etc. Deciduoma. — The name deciduoma has been applied to a form of uterine new growth occurring in connection with pregnancy which was formerly thought to occur as a result of the proliferation of the cells of the decidua, but which recently have been shown to have their origin more frequently in the chorion. Between the benign form known as hydatiform mole and the malig- nant forms known as syncytioma or chorionepithelioma there is no sharp dividing line, although most hydatiform moles are clearly benign and most chorionepitheliomata are excessively malignant. The tendency to the occurrence of chorionepithelioma after the forma- tion of hydatiform mole is well marked, this connection having been established in about 40 per cent, of the cases on record. Hydatiform or vesicular mole is a form of new growth having a resemblance to a bunch of grapes, which has its origin in the chorionic villi. The translucent vesicles, of which it is formed, contain a clear fluid, vary in size from that of a millet seed to an acorn, and spring from other vesicles or from the chorion by independent pedicles. There is a tendency for the chorionic villi, in this condition, to infil- trate the uterine wall. The varying degree of this infiltration is a factor which makes the borderline between the benign and the malignant deciduomata an indistinct one. Recently attention has been called to the intimate relationship between the occurrence of hydatiform mole and lutein cysts of the ovary. Chorionepithelioma. — The malignant form of deciduoma is usually known as chorionepithelioma. These tumors usually contain elements derived from both layers of the chorion — Langhan's cells and the multinucleated cells of the syncytium. Inasmuch as they always include the syncytial layer, they are sometimes known as syncytioma. Their most important clinical feature is their tendency to produce frequent and profuse hemorrhage. They possess a great tendency to form early and extensive metastasis because of the proclivity which 96 TUMORS the chorionic epithelium exhibits of penetrating the capillaries. They are among the most malignant of tumors. To the naked eye the tumor appears on section as a soft, reddish mass. Microscopically, it is composed of large polynuclear cells or cell masses — syncytial masses — appearing in regular multinuclear strands, and of more transparent, sharply circumscribed, polyhedral cells, with single oval nuclei. They often contain free blood and fibrin, and the stroma is largely made up of the tissue they invade. Hypernephroma. — The name hypernephroma has been applied to a form of tumor found mainly in the kidney, arising from adrenal nests or masses of accessory suprarenal tissue, having the structure of the zona fasciculata of the suprarenal body. As a rule, hypernephromata are malignant, although they may be benign. They occur most commonly in persons past middle life, and may form metastases, which extend along the blood stream to the lung, liver, muscles, and frequently to the long bones. In the kidney the tumor is usually encapsulated and situated near the cortex. Hypernephromata histologically present wide variations which ap- proach in type the carcinomata, endotheliomata, and angiosarcomata. The stroma is composed largely of a network of capillaries, in the meshes of which the cells are enclosed. An alveolar appearance is often seen. The cells are large, polyhedral, and retractile, containing fat and glycogen droplets. The cells, lying directly upon the endothelium of the capillaries, often present a tubular arrangement. Mitosis is frequently abundant, and the central areas of the tumors are very prone to undergo degen- eration. Interstitial hemorrhages are common and often profuse. While Lubarsch considered the presence of glycogen characteristic of hypernephromata, this view is no longer tenable, as many embryonic tissues and freely growing tumors contain glycogen in their cells. Psammoma. — Psammomata are small lobular tumors, often multiple and pedunculated, growing from the inner surface of the dura mater or the pia mater. They are usually composed of tissue fibres, sarcoma- tous or endotheliomatous in character, and contain variously shaped calcareous concretions similar in appearance to the so-called brain sand. CYSTS. A cyst is a closed sac, containing fluid or pultaceous matter — a form of new growth, although not a tumor in the strict sense of the word. Cysts may be classified as follows: I. Cysts formed by distention of pre-existing cavities. II. Cysts of new formation. III. Congenital cysts. I. Cysts Formed by Distention of Pre-existing Cavities. — These are divided into three groups: (a) Exudation cysts; (b) retention cysts; (c) extravasation cysts. CYSTS 97 Exudation Cysts. Exudation cysts are those which arise from the distention of cavities which have no secretory ducts, such as thyroid, Graafian follicles, and bursa*. In the thyroid this gives rise to a cystic goitre. Graafian follicle cysts may be multiple, with coalescent walls and communications between adjacent cavities. These are not to be confused with cystadenomata and papillary cystadenomata. Bur- sal cysts occur most commonly in the larger bursse— -prepatellar and olecranon — and in those bursse over the tuberosity of the ischium and the great trochanter. Retention Cysts. — \Vhen the duet of a gland becomes obstructed, the secretion, hindered from escaping, accumulates and causes a dilatation of the ducts and acini. Examples of this form are sebaceous and mucous cysts and the so- called duct cysts of the salivary and lacteal glands, liver, kidney, and testicle. Sebaceous Cysts. — Sebaceous cysts or wens result from physical change of secretory material so that mechanically the contents accu- mulate and also from obstruction in the excretory duct. The secre- tion collects and forms a tumor. These tumors are especially common on the face and scalp, but may occur on any part of the body. They are smooth, round, circumscribed, movable on the deeper parts, soft and putty-like in consistence, and contain inspissated creamy material. A small, black spot may sometimes be detected on the surface of the skin over them, where the duct opens. Mucous Cysts. — Mucous cysts are formed by the dilatation of mucous glands following obstruction of their ducts. They are most common in connection with the salivary glands. When these occur in the mouth, they are known as rauulce. Other common examples are the cysts formed by the dilatation of the glands of Bartholin at the entrance of the vagina. Extravasation Cysts. — Extravasation cysts are formed by the extrav- asation of blood into closed cavities, as the tunica vaginalis of the testicle (hematocele), etc. II. Cysts of New Formation. — These are divided into four groups: (a) Serous cysts. (b) Degeneration cysts. (c) Parasitic cysts. (d) Implantation cysts. Serous Cysts. — Serous cysts are supposed to be formed by the accumulation of fluid as the result of irritation, pressure, etc., in the lymphatic spaces of the connective tissue, these spaces subsequently becoming fused into a single cavity. Adventitious bursa? developed over prominences of bone are the most common examples of this form. Degeneration Cysts. — Degeneration cysts result from degeneration and liquefaction occurring in the substance of tumors, especially those which are succulent and of rapid growth. Old abscesses may also change into well-defined cysts of this kind. 7 98 TUMORS To this group may also be added the ganglia, which are cysts formed in connection with the connective-tissue structures through degenera- tion, in the majority of cases, of connective tissue. They occur about a joint, as in the sheath of a tendon, and are most commonly seen on the dorsal aspect of the carpus or tarsus. Parasitic Cysts. — Parasitic cysts are produced by the growth within the tissues of cyst-forming parasites, the best known being the tenia echinococcus, which gives rise to the hydatid cyst. Although hydatid cysts may occur in any of the tissues and organs of the body, they are most frequently found in the liver. Fig. 35. — Echinococcus cyst of liver. Triangular area of cyst wall removed showing daughter cysts. The ova of the parasite, transmitted from the dog, gain admission to the human intestine, are there hatched, and the embryos are thence transported to some other part of the body, usually by the portal vein, where they lodge and form cysts. These cysts are formed of an external laminated elastic layer, the ectocyst, and of a lining mem- brane or parenchymatous layer, the endocyst. From this inner layer brood capsules may develop from which daughter cysts may form, and from these in turn granddaughter cysts may develop. Implantation Cysts. — Implantation cysts, or traumatic dermoids, are formed by the displacement of portions of the epidermis through a punctured wound into the underlying connective tissue. The dis- CYSTS 99 placed epithelium proliferates and forms a small cyst, the most fre- quent site of which is on the palmar aspect of the hand and fingers. III. Congenital Cysts. — These are divided into two group-: (a) Dermoid cysts. (6) Cysts from persistent fetal structures. Dermoid Cysts. — Dermoid cysts of the simplest form, known as sequestration dermoids, arise in detached and sequestrated portions of the surface epithelium, mainly in situations where, during embry- onic life, coalescence takes place between skin-covered surfaces. They are found in the midline of the trunk, from the occipital protuberance along the spine to the coccyx, through the perineum (including the scrotum and penis) and through the midline of the abdominal and thoracic wall of the neck. In the face and neck they arise in the lines of the facial and branchial fissures. Fig. 36. — Ovarian dermoid bisected. A dermoid occasionally takes the form of a recess lined with skin, examples of which are postanal dimples, the coccygeal or pilonidal sinuses; but more commonly it assumes the form of a globular tumor, consisting of a central cavity lined by stratified squamous epithelium. This cavity is filled with a turbid fluid containing desquamated epithelium, fat-droplets, cholesterine crystals, and detached hairs. Ovarian dermoids differ in several respects from the preceding. They arise from the epithelium of the ovarian follicles, and take the form of unilocular or multilocular cysts, the wall of which con- tains skin, mucous membrane, hair follicles, sebaceous, sweat, and The cavity of the cyst usually contains a pultaceous mixture of shed mucous glands, nails, teeth, nipples, and mammary glands (Fig. 36). epithelium, fluid fat, and hair. 100 TUMORS Cysts from Persistent Fetal Structures. — These occur in obsolete canals and functionless ducts. Among the former, existing in the human embryo, but usually disappearing before birth, are the thy ro glossal duct, the branchial clefts, and the postanal gut. Cysts derived from these structures are frequently called tubulodermoids. Cysts of the latter, frequently called tubulocysts, arise in connection with the vitello-intestinal and Gartner's ducts, the urachus, the paro- ophoron, and the parovarium. CHAPTER VI. SHOCK AND ALLIED CONDITIONS. SHOCK. As a result of injury or strong mental (psychic) impressions a con- dition of depression may result which is called shock. The degree of shock, as represented by clinical manifestations, varies within wide limits. Thus, there may be only a feeling of slight weakness or a temporary loss of consciousness; on the other hand, there may be evidences of complete disorganization of the vital processes from which death quickly results. The Explanation of Shock. — The majority of writers and investi- gators have taught that the all-important factor in the development of shock is loss of vasomotor control. This vasomotor theory apparently was suggested first by Mitchell, Keen and Morehouse. 1 Fisher as- sumed that as a result of vasomotor paralysis large quantities of blood accumulate in the splanchnic veins and that the heart and other por- tions of the vascular system are comparatively empty. This inter- pretation of shock was generally accepted. Yet some writers have sought to explain the phenomena of shock in other ways. The theory has been advanced that the condition is due to impairment of the func- tions of the brain by anemia, caused by contraction of the bloodvessels. Howell 2 advanced the theory that "the condition is due fundamentally to a strong inhibition of the medullary centres (vasoconstrictor, cardio- inhibitory) leading to a long continued suspension of activity, partial or complete." Meltzer 3 attributes the symptoms to a tendency to overactive inhibition, that is, stimulation of nerve fibres which cause inhibition will inhibit more than in a normal state. Yandell Hendersen presented the theory that the symptoms are due to reduction of C0 2 in the blood (acapnia). Crile, 4 as a result of extensive experimentation, has elaborated the vasomotor theory and has done much towards explaining the basis of shock. His experiments seem to show that as a result of severe mechan- ical injuries, especially painful injuries, also as a result of profound psychic influences of various kinds, impulses are conveyed to the brain by the sensory nerves. These afferent impulses are assumed to be the 1 Circular 6, Surgeon General's Office, 1864. 2 Contributions to Medical Research, 1903. 3 Arch, of Int. Med., 1908, i, 571. 4 An Experimental Research in Surgical Shock, 1899; Crile and Lower, Anoci Asso- ciation, Philadelphia, 1914. 102 SHOCK AND ALLIED CONDITIONS primary etiological factor in the development of shock, whether of trau- matic shock or of psychic shod;. These impulses through their effect upon the central nervous system cause disturbance of vasomotor con- trol, embarrassment of respiration and diminution or arrest of the heart action. While all of these factors are present in cases exhibiting evi- dences of a considerable degree of shock, injuries to certain regions of the body seem to accentuate one or more of the factors; for example, injuries to the interior of the larynx or thoracic cavity may cause instant cessation of respiration; injuries to the male genital organs, the pericardium or adjacent portions of the diaphragm cause irregularity, weakness, or arrest of the heart action; while irritation of the perito- neum may give rise to marked dilatation of the splanchnic vessels and rapid fall of blood-pressure. In Crile's experiments it was found that, although the first effect of a given trauma was usually a transitory rise in the blood-pressure, after repeated applications of the injuring force the preliminary rise did not occur, but a progressive and permanent lowering of the blood- pressure resulted. Injury to certain tissues, as the interior of the larynx, the testicle, and certain abdominal viscera were often followed by a rapid fall of blood-pressure without the preliminary rise. Crile has assumed that some change occurs in the vasomotor centres which results in an abnormal lowering of the blood-pressure and that this is an important factor in shock. Crile's experiments also show that the integrity of the circulation, that is, the maintenance of the blood-pressure, depends in large measure upon the regularity, force and output of the heart. The out- put of the heart depends upon the supply of blood reaching it from the vense cava?; this supply depends upon the pressure in the large venous trunks; the venous pressure depends upon the integrity of the vaso- motor mechanism. Thus, any agent which produces vasomotor paresis, diminished pressure in the large venous trunks or weakened heart action will favor the development of a vicious cycle. Under such conditions, comparatively little blood is in circulation; the great bulk is probably stored in the venous system. As a result, the supply of oxygen to the tissues undoubtedly is greatly diminished, and the effect of this on the central nervous system presumably is to produce impairment or cessation of all its functions. That respiratory changes are associated with lowered blood-pressure is apparent in many of Crile's experiments. Whenever an injury resulted in marked lowering of blood-pressure the respiration became shallow, irregular and often ceased entirely. In 90 out of 103 experi- ments respiratory failure was the immediate cause of death. While the belief is general among the profession that in shock the immediate cause of death is failure of the heart, Crile considers that the weak- ness of the heart is only apparent and is due to the fact that the amount of fluid brought to it is so reduced that its output is necessarily small, and that its rapid action is an effort to increase this output and SHOCK 103 to raise the blood-pressure. This view is substantiated by the prompt improvement in the action of the heart which often results from the administration of saline infusion intravenously. Morbid Anatomy. — Concerning the pathological changes in shock various findings have been reported: Meltzer states that there are no postmortem changes and that the fatal disturbances underlying shock are exclusively of a functional nature. This is the view held by most authorities. On the other hand Crile 1 reported that the following conditions were found at autopsy in animals which had died as a result of shock. The large venous trunks were full, the arteries empty; the splanchnic veins were not more distended than the somatic. The left ventricle and auricle usually contained some blood, the right ventricle little or none. The lungs were anemic; the pulmonary vessels empty. The liver, spleen and kidneys were enlarged. It has been claimed by some that there is an increase in the specific gravity of the blood. 2 Crile and Lower have recently reported that microscopical exami- nation of the brains of dogs in various stages of shock induced by severe traumatism showed "first, a hyperactivity characterized by hyperchromatism (marked chromo- philic properties of the Xissl bodies) ; later, a stage of exhaustion char- acterized by chromatolysis (with disappearance of the Nissl bodies), disturbance of nucleus-plasma relation, rupture of nuclear and the cell membranes and finally disintegration. These changes were most marked in the cortex and the cerebellum but were also present in the medulla and the cord. They state that the cells of the liver and adrenals show corresponding changes, represented by generalized disappearance of the cytoplasm. On the basis of these histological changes Crile has founded the "Kinetic Theory of Shock." The Kinetic Theory of Shock. — The kinetic theory of shock postulates that all forms of shock are caused by overstimulation and consequent exhaustion; that the cells of the brain, the suprarenals, and the liver show physical changes corresponding to each change in the clinical cycle of shock; and that these cellular changes constitute the essential lesions of shock and are caused by the conversion of potential energy into kinetic energy at the expense of certain chemical compounds stored in the affected cells. However, it has not been shown what relationship exists between the histological changes and the mani- festations of shock which are noted clinically and experimentally. In Fig. 37. — Changes seen in brain cells of a rabbit subjected to fear. Area from cerebellum; characteristic changes in Purkinje cells in fright. (From Crile "Anoci-association.") 1 Surgical Shock, Philadelphia, 1899. 2 Cf. Vale, Med. Record, 1904, Ixvi, 352. 104 SHOCK AND ALLIED CONDITIONS other words the occurrence of the cellular changes does not explain the phenomena of shock. To summarize: Shock is dependent upon afferent impulses which may be excited by trauma, psychic influences or both; these impulses pass to the central nervous system and cause primarily disturbance of vasomotor control, embarrassment of respiration and diminution or arrest of the heart action; of these the most important factor is the loss of vasomotor control, which is represented by lowered blood- pressure. With the clinical manifestations of shock are associated certain histological changes in the brain, adrenals and liver. Etiology. — Shock may be caused by any agency which produces a violent impression upon the central nervous system through the medium of the nerves of sensation or special sense; violent emotions have frequently been observed to cause syncope and even death (psychic shock). Surgical shock in the great majority of instances is caused essentially by bodily injury which may be the result of accident or surgical operation; however, psychic influences may be, and fre- quently are, associated with the traumatic and may act as accessories in the development and prolongation of shock. Regarding the conditions which favor the occurrence of shock, it may be stated that lowered vitality from any cause, and an abnormally impressionable nervous system, are conditions in which a severe degree of shock may be expected. Thus, early youth and old age; malnutrition; exhaustion from suffering, prolonged physical effort or insomnia; uremia; chronic poisoning from alcohol, drugs, etc., are to be regarded as predisposing factors. Highly impressionable individ- uals, as a rule, show a greater reaction to slight injuries than do the more phlegmatic, and in such persons the anticipation of injury or pain will often greatly accentuate the resulting impressions. Since loss of blood alone will produce a condition very similar to shock, it is evident that injuries associated with a considerable degree of hemorrhage will be accompanied by more profound shock than bloodless injuries of the same extent and character. Certain types of injury produce intense shock, notably crushing injuries and extensive burns. Crile has shown that injury or even irritation of certain regions of the body gives rise to a far greater degree of shock than more severe trauma elsewhere. He found that compara- tively slight injury to the mucous membrane of the larynx produced sudden cessation of respiration, cardiac inhibition, and a rapid decline in the blood-pressure, even when the animal was under general anes- thesia. After division of the superior laryngeal nerves or cocainiza- tion of the parts these effects were not apparent. Direct pressure on the heart, pericardium, and great vessels produced great irregularity and weakness of the heart and a lowering of blood-pressure. Tapping the under surface of the diaphragm caused marked respiratory dis- turbance and cardiac weakness. Injuries to the testicle and lung, pulling upon the mesentery, manipulation of the parietal peritoneum, SHOCK 105 and manipulations in the region of the pylorus, gall-bladder and duo- denum, all caused an exaggerated degree of shock; while injuries to the pelvic organs (especially in the female) and manipulation of the omentum gave rise to comparatively little disturbance. Incisions or wounds in the skin gave rise to a far greater degree of shock than similar injuries to the muscles, tendons, fatty tissues and fascia-. Injuries to or even traction upon nerve-trunks was accompanied by considerable systemic disturbance; while injuries to the bones and large joint-, when unaccompanied by injuries to the nerves, produced little reaction. When the animal was in a condition of shock from repeated trauma or had recently passed through such a condition, it was found that additional injury, even of moderate degree, was accompanied by a further lowering of the blood-pressure. This lowering of the blood-pressure was wholly out of proportion to the degree of the injury, and the reaction from it was much delayed or even absent. The depressing influence of an anesthetic may add a potent factor which is accentuated if the anesthetic is badly administered. Loss of body heat, as a result of a cold operating room, exposure of the patient or of the viscera, also rough handling of the tissues, especially the abdominal viscera, likewise favor shock. In general it may be stated that the degree of shock depend- upon the character and extent of the injury, its location, the kind of tissues involved, the amount of hemorrhage, and the temperament and mental condition of the patient. Symptoms. — The symptoms of shock vary with the site, severity and character of the injury and with the susceptibility of the patient. In mild cases the patient complains of a feeling of weakness, slight nausea, and giddiness. The face is pale, the extremities cold and often bathed in perspiration, the pulse is weak, and there is a tendency to syncope if the patient is in the upright position. In more marked cases there may be a temporary loss of consciousness; the patient is unable to sit up, lies quietly, and takes little or no interest in his surroundings; he will answer questions; does not complain of pain; and evidently wants to be left undisturbed. In the severer cases con- sciousness is almost entirely lost; the face is expressionless; the eyes are fixed, the pupils dilated and react slowly to light; there is no apparent suffering even though a portion of the trunk is extensively mangled or an extremity crushed. The surface of the body is cold and moist; the pulse is rapid, irregular, compressible and extremely weak; respiration is rapid, irregular, shallow and gasping; the temperature is subnormal; the sphincters may be paralyzed; the patient makes no effort to move, but lies in any position in which he is placed. Vomit- ing may occur, and in alcoholics there may be tremor and delirium. Exceptionally, in the severest cases, restlessness and delirium may be the most prominent symptoms even in non-alcoholics. A low blood- pressure is usual, although it is not essential to the production of 106 SHOCK AND ALLIED CONDITIONS shock. 1 (A. R. Short. 2 ) "In a series of experiments in which blood counts were made before and after the production of shock it was found that there was an enormous decrease of white blood cells in the shocked animal." (Mann.) To summarize: The most conspicuous clinical features in shock are apathy, pallor, extreme weakness, cold, moist, clammy skin, diminished sensibility, lowered blood-pressure, rapid, weak, and irregular pulse, rapid, irregular, and shallow respirations. Differential Diagnosis. — Shock and hemorrhage have so many symp- toms in common that it is often difficult to make a differential diag- nosis. The question may be a serious one, especially after operations, as it is most important to know whether a given condition of weakness is due to the shock of operation or to concealed hemorrhage. In gen- eral it may be said that in shock the patient is weak and apathetic, while in hemorrhage he is weak and restless. Frequent examinations of the blood should be made in doubtful cases; a progressive diminu- tion of hemoglobin and the red cells indicates hemorrhage. Prognosis. — The prognosis in severe shock is always grave, and until there is a decided and sustained improvement, the outlook should be regarded as doubtful. In the milder cases recovery may be expected if the cause of the depression can be removed and appropriate treat- ment can be carried out. Conditions which add to the gravity of a given case are the combination of shock with hemorrhage, anemia, delirium tremens, brain injury, arteriosclerosis, or a heart weakened by chronic valvular disease, myocarditis, or fatty infiltration. Treatment. — The treatment w T hich is usually employed for shock has been based chiefly upon clinical observation and clinical expe- rience. Recent experimental investigations, however, indicate that the long accepted methods of treatment must be modified. The suggested modifications of the usual routine, as noted below, have been outlined by Lieb. "Traumatic shock is almost always complicated by more or less profound psychic shock. Therefore, the first indication for treatment is to numb the consciousness of the patient by the subcutaneous injection of morphine." The patient should be moved as gently as possible and hemorrhage should be controlled. " If possible the site of injury should be physiologically isolated from the central nervous system by blocking afferent nerves, either by the injection of cocaine around the area, or by its injection into a nerve trunk. Even after an attempt has been made to isolate the injured area, manipulation should be gentle, because complete isolation is difficult, and if a single nerve is not blocked impulses may reach the central nervous system and deepen shock." The local blocking is indicated even when general anesthesia is employed." 1 Mann, Bull. Johns Hopkins Hosp., 1914, xxv, 205; Janeway and Ewing, Annals of Surgery, 1914, lix, 158. 2 The Newer Physiology in Surgical and General Practice, 1914. SHOCK 107 The ideal treatment for shock has been shown by Crile and Lower to be the direct transfusion of blood. This should be employed when possible in all cases with low blood-pressure. However, intravenous infusion of hot normal salt solution is usually depended upon as the sheet anchor in the treatment. The infusion should be given slowly at the temperature of 116° to 118° F., and in sufficient quantity to pro- duce distinct improvement in the pulse and heart action. Repeated infusions of comparatively small quantities apparently have a better effect than a single large infusion. Adrenalin, which raises the blood- pressure, is often administered with the infusion. About 1 to \\ c.c. is the usual dose; 1 c.c. may be added to 500 c.c. of salt solution. A better method, which was suggested by Crile, is to thrust the needle of a hypodermic syringe, tilled with adrenalin chloride 1 to 1000, through the rubber tube near the cannula while the infusion is being given; Crile injects 1 to 2 c.c. in one minute. It appears, however, more safe and more effective to give smaller amounts, for in- stance, 0.3 c.c. at two-minute intervals for four or five doses. Heiden- hain 1 recommends combining pituitrin with the adrenalin, believing that the action of the adrenalin is prolonged and rendered more effec- tive; they are given intravenously, 0.6 c.c. of 1 to 1000 adrenalin and 1 c.c. of pituitrin being added to one litre of salt solution. Hypo- dermoclysis is sometimes substituted for infusion but is not to be recommended. Prior to the transfusion or infusion the foot of the bed should be raised or the patient placed in the Trendelenburg position. The use of the pneumatic rubber suit was recommended by Crile to drive the blood from the extremities and trunk into the brain, but it is rarely used. The same object may be accomplished more simply by bandag- ing the extremities. Drugs. — A variety of drugs, especially stimulants, have been recom- mended for the treatment of shock and are in general use. Thus, atropine and small doses of strychnine are given hypodermically; atropine to prevent the inhibitory vagal influence which has been sup- posed to be present in shock, strychnine for its action on the heart- muscle and vasomotor centres. Whisky is administered by the mouth, hypodermically, or by the rectum; when given by the bowel, it is often combined with hot coffee. Other stimulants, such as camphor, caffeine, ether and digitalis are employed hypodermically. Since a low blood-pressure is one of the most important elements in shock, the use of nitroglycerin, or other vasomotor dilators is generally condemned. On the basis of extensive experimentation, Lieb offers the following criticisms of the use of drugs. " Drug treatment is not usually effective. Strychnine is contraindicated. It acts chiefly on the spinal cord and by opening up new paths for the transmission of impulses tends to 1 Deutsch. Zeitsch. f. Chir., 1914, cxxvii, 202. 108 SHOCK AND ALLIED CONDITIONS magnify the effect of each afferent stimulus. The object of treatment should be to block, not to facilitate the transmission of impulses. Caffeine, whether as the pure alkaloid or in the form of coffee, is also to he avoided. On the eord it acts like strychnine; in addition, it stimulates the higher cerebral centres, and by arousing the patient to more complete consciousness adds psychic shock to traumatic. Whiskey, camphor, tincture digitalis, or ether given subcutaneously produce marked local irritation, that is, they cause pain. Since pain is one of the chief causes of shock the injection of irritants or pain- producing drugs under the skin increases the exciting cause and should be avoided. It must be repeated that the central nervous system should be guarded against afferent stimuli; therefore, unless it is urgently indi- cated, no irritant drug should be employed by inhalation, by mouth, by rectum, subcutaneously, or by any other channel of administration. Summary of Treatment. — Morphine should be given to desensitize the patient; body heat should be conserved; the site of injury should be blocked from the central nervous system; the blood-pressure should be raised and the volume of the blood increased, preferably by transfusion, otherwise by intravenous saline infusions with adre- nalin. Stimulants which act upon the central nervous system are for the most part useless and may be harmful. They should be em- ployed only in cases of extreme shock in which death seems imminent and immediate stimulation is imperative while other means of treat- ment are under preparation. Prophylaxis. — In general, surgical operations should not be under- taken during a condition of severe shock. To this rule, however, there are many exceptions; hemorrhage must be controlled, certain penetrat- ing wounds of the thorax and abdomen must be explored, strangulated hernias must be relieved, etc. Under such conditions, when general anesthesia is necessary, nitrous oxide and oxygen or ether should be employed, preceded by a hypodermic injection of morphine and atro- pine. An intravenous saline infusion may be begun when the patient is under the anesthetic. Elaborate preparation of the wound area should not be undertaken in cases with infection well established. The anesthesia should be smooth and even; an overdose of the anes- thetic causes a fall in blood-pressure which predisposes to shock. The operation should be rapid, the manipulations gentle, dissections clean cut, hemostasis thorough and the exposure of cut surfaces and viscera reduced to a minimum. In undertaking operations where from the nature of the operation or the condition of the patient considerable shock is to be expected, certain precautions should be observed. If delay is possible the con- dition of the patient should be rendered as favorable as possible by rest, food, free administrations of fluids, etc. The operating room should be warm and the anesthetizing room quiet. A preliminary hypodermic of morphine should be given, especially in nervous and FAT-EMBOLISM 109 apprehensive individuals. It is of advantage to operate at a time when a patient is in the best physical condition to withstand depres- sing influences. Generally speaking, patients are at their best in the early part of the day. The general precautions mentioned above in regard to anesthesia and operative teehnie should be carefully observed. Harvey dishing has emphasized the importance of watch- ing the blood-pressure during operations which are likely to be accom- panied by severe shock, as variations in pressure are far more significant in indicating shock than changes in the pulse rate. In connection with the prevention of operative shock, Crile attaches much importance to anoci association, the principle of which is "the exclusion of all harmful stimuli, making the brain and the personality of the patient unmodified and unimpaired through the operation." He advances the theory that the exclusion of both traumatic and emotional stimuli will wholly prevent the shock of operation. In the application of anoci association, psychic influences, such as ante- operative anxiety and excitement are minimized by the administra- tion of morphine and scopolamine before the operation; operative unrest and physical suffering are eliminated by the employment of general anesthesia. Crile recommends nitrous oxide and oxygen. In very impressionable patients, such as those having exophthalmic goitre, Crile attempts to perform the operation without the patient's knowledge — "to steal the gland." He believes that ether and other general anesthetics do not break the afferent paths for stimuli from the seat of injury and offer no protection to the brain cells against the effect of operative trauma. In order to prevent impulses from the field of operation, the division of tissues is preceded by complete local blocking through circumferential injections of novocain. Before closing the wound quinine and urea hydrochloride is injected around the whole exposed field in order that afferent impulses may be prevented for several days after the operation. FAT-EMBOLISM. As a result of fractures and other traumata small globules of fat may enter the blood current and be carried to the lungs. These fat globules may plug the pulmonary capillaries or be forced through the lungs and be deposited in the brain, kidneys, spleen, coronary arteries, and other tissues. Almost all cases of fat-embolism occur in connection with the sur- gery of the bones and joints, that is, in connection with fractures, the manipulation of contracted joints and operations upon bones. It is generally believed that the fat enters directly into ruptured veins of the bone marrow, but Ribbert considers that the fat droplets may be taken up by the lymphatics. The use of the Esmarch bandage in bone operations has been said to predispose to embolism by favoring 110 SHOCK AND ALLIED CONDITIONS the sudden admission of fat into the circulation on the removal of the bandage. Most cases occur after the age of fourteen, according to v. Aberle. 1 He considers that the explanation lies in the peculiarities of the devel- opment of the bone marrow. Infantile shaft bones, in the first years of life contain only red marrow, very poor in fat; whereas after about the fourteenth year the marrow of the shaft bone usually consists essentially of fat. Fat-embolism is noted relatively frequently follow- ing the manipulation of joints which present marked contractions and atrophic bones, such as may follow poliomyelitis and rheumatism. This predominant occurrence of fat embolism with injury to atrophic bones is explained by the fact that in atrophy the solid osseous substance that is lost is largely replaced by fat. The main factors, therefore, in these cases are the more or less advanced osteoporosis and the presence of yellow fat marrow. Under such conditions fat- embolism results from the fracture and compression of the osteoporotic bone. Grondahl has recently discussed the occurrence of fat-embolism after injury to the soft parts and internal organs, about which very little has been published. His collected cases include 36 injuries to the subcutaneous tissues, through knife-thrusts and operative wounds. Some of the patients died soon after the surgical intervention, some survived from one to ten days. The operations were of almost all varieties, including the thoracic and abdominal cavities, but there were no operations involving tissues which contain an excessive amount of fat, such as the breast. Symptoms. — The clinical picture of fat-embolism is a complex of the symptoms due to involvement of the different organs; it varies with the degree to which each is affected. The symptoms due to in- volvement of the lungs predominate as a rule. The symptoms and signs which result from pulmonary emboli are dyspnea, cyanosis, expectoration of frothy blood-stained sputum and signs of pulmonary edema. Emboli lodged in the brain may give rise to restlessness, con- vulsions, delirium, and somnolence; in a very few cases focal symptoms have been reported. The patient's condition may suggest meningitis. If emboli become lodged in a coronary artery the heart action is seriously affected; the pulse becomes rapid and thready; sudden arrest of the heart may occur. Fat-emboli in the spleen and kidneys are not, as a rule, associated with significant symptoms; hematuria appears to be of exceptional occurrence; but severe pain in the back 1 Ueber Fettembolie nach orthopaedischen Operationen, Zeitschrift f. orthopaedische Chirurgie, 1908, xix, 89; Gangele, Ueber Fettembolie und Krampfanfalle nach ortho- paedischen Operationen, Zeitschrift f. orthopaedische Chirurgie, 1914, xxxiv, 193; Grondahl, Untersuchungen iiber Fettembolie, Deutsche Zeitschrift f. Chirurgie, 1911, iii, 56; Schanz, Zur Behandlung der Krampfanfalle nach orthopaedischen Operationen, Centralblatt f. Chir., 1910, No. 2, 43; Wierzejenski. Ueber Unfalle und Komplikationen bei orthopaedischen Operationen, Verhandlg. d. Deutsch. Ges. f. Orthopaed. Chir. X Congress, 1910. STATUS LYMPHATICUS 111 is often ascribed to renal emboli. With fat-embolism free fat may be found in the urine, and ecchymotic spots may occur in the skin, mucous membranes and conjunctiva?. The temperature is usually slightly elevated or subnormal; if there is a marked rise pneumonia should be suspected. The symptoms usually do not begin until the second to the fourth day after the fracture, operation or other surgical intervention, such as change of fixation dressing; but occasionally they make their appearance immediately. The symptoms may be extremely mild and the true condition may readily pass unrecognized; in fact it is generally believed that fat-embolism may occur without giving rise to any symptoms. In cases of moderate severity spontaneous recovery is the rule. In severe cases somnolence and coma usually develop and death may ensue; but in some cases of the pulmonary type with signs of extreme edema of the lungs consciousness may be retained almost to the time of death. Sudden death occasionally occurs. Treatment. — It is important to recognize the factors which favor the occurrence of fat-embolism and to exercise extreme care under these conditions in manipulations and operations upon the bones and joints. Immediate treatment should consist in absolute rest of the injured part and cardiac stimulants as indicated. Amy] nitrite and the inhalation of oxygen have been recommended. Schanz, Gangele, and others consider that the proper method of treatment of fat-embo- lism is immediate and frequently repeated administrations of salt solu- tion subcutaneously or intravenously in order to dislodge the emboli. It appears questionable whether this method is reallv effective. If it is effective there is risk that the displaced emboli will become lodged elsewhere and prove equally serious. However, the advocates of the method claim that it has repeatedly been proved to be efficient; moreover, the chances are good that dislodged emboli will come to rest in relatively harmless positions. Therefore, the method appears justifiable in the presence of serious symptoms. STATUS LYMPHATICUS. Status lymphaticus is a condition of lowered resistance associated with certain changes in the lymphoid tissues, and characterized, especially in adolescence and adult life, by more or less well defined physical peculiarities. The chief importance of the condition is due to the marked susceptibility of infants and children of this type to infectious diseases, especially tuberculosis. Of vital importance to the surgeon is the fact that individuals presenting status lymphaticus often die suddenly and unexpectedly during an operation. Efforts have been made, with some success to differentiate anatomic- ally and clinically between conditions dependent upon (1) the thymus alone (status thymicus), (2) the general lymphatic tissues exclusive 112 SHOCK AND ALLIED CONDITIONS of the thymus (status lymphaticus), and (3) those dependent upon both the thymus and the general lymphatic tissue- (status thymico- lymphaticus. We will not attempt to differentiate between these subdivisions, but will consider them collectively under the general term 'Status lymphaticus." Status lymphaticus was first described by Paltauf, 1 and for many years it was supposed to lie of very exceptional occurrence. At present, however, it is noted not infrequently. Undoubtedly many cases were formerly overlooked both clinically and at autopsy. There appears to be in some cases a family predisposition to status lymphaticus. There is reason to believe that maternal tuberculosis and syphilis are of etiological importance. Morbid Anatomy. — Persistence of the thymus is a frequent and significant feature: histologically, the thymus presents simple hyper- plasia of the lymphoid cells. There is also hyperplasia of the lymph nodes, especially the cervical, tracheobronchial and mesenteric, and hyperplasia of the lymphoid tissue of the fauces, tongue, pharynx, digestive tract and spleen. In many cases there is hypoplasia of the aorta and of the genital organs. Other changes have been reported, for instance, excentric left sided cardiac hypertrophy and hypoplasia (if the chromaffin system. (Hedinger.) 2 Symptoms. — The symptoms and objective signs have been summar- ized by Emerson as follows: In man there is scantiness of hair on the chin and upper lip, -canty axillary and sternal hair, scanty or feminine distribution of the pubic hair; slender thorax; rounded contour of the upper arms and thighs with an arching of the latter; hypoplastic external genitals and a delicate velvety skin. Less con- stantly there i> found hyperplasia of the lymphoid tissue of the nose, throat and tongue and an increase in the palpable superficial lymph nodes, especially the cervical and axillary nodes. Emerson considers that the following features are so inconstant as to be of little value in arriving at a diagnosis; the character of the hair of the head, which is supposed to be commonly coarse and straight in status cases; slender columnar neck, rounded feminine abdomen and enlargement of the spleen. In women the features to emphasize in status lymphaticus are the peculiar character of the skin of the body and extremities, the scanti- ness of the axillary hair pad, the scantiness of pubic and perineal hair and hypoplasia of the genital apparatus. Some women of decided status conformitv have a marked growth of hair on the face and upper In infants there are frequently no symptoms nor physical signs to suggest the existence of status lymphaticus. But many of these cases suffer from attacks of laryngospasm with convulsive movements, show enlargement of the tonsils, spleen and superficial lymph nodes and Wii b. klin. Wchnschr., L889, ii. ^77. - KorrespondenzbJatt f. Schweizer Aerate, 1907, X". Hi, 521. ST A T US L YM PHA TIC US 113 present complications, such as eczema and changes in the bones resembling rickets. Moreover, children of this type are usually pale and pasty in appearance and often show marked adiposity. "Both children and adults with status lymphaticus are especially apt to die (suddenly) from slight external causes, such as shock, im- mersion in cold water, local or general anesthesia, during the course of infectious diseases, and following injections of diphtheria antitoxin (and salvarsan)." (Cocks.) Operative Deaths. — The majority, but not all, of the operative deaths have followed the use of chloroform. Death may occur at any stage of the anesthesia, or after the patient apparently has recovered from its effects. McCardie 1 has described the manner of death as it occurred in reported cases: "In certain of them facial pallor and di- lated pupils were first noticed and then it was found that cardiac action had stopped. In others respiration was observed to become superficial and intermittent and at the same time the pulse was impalpable; in yet others cyanosis first appeared together with dyspnea, the circula- tion quickly failing afterwards. In another type of case there was sudden failure of circulation and respiration, apparently simulta- neously." The age of the patients in McCardie's series was from six months to fifty-five years. Diagnosis. — The recognition of the existence of status lymphaticus is of vital importance when an operation is under consideration. A history of one or more sudden unexplained deaths in other members of the patient's family, or attacks of stridulous breathing or severe dyspnea during the first year of life should cause careful investigation for evidences of status lymphaticus. In adults the clinical manifes- tations can usually be recognized readily. In infants a definite diag- nosis is more difficult and is largely dependent upon the recognition of enlargement of the thymus. This is aided by percussion, z-rays and tracheoscopy. Percussion, according to Jacobi, should be made with the child held face downward. The dulness of the thymus corre- sponds to a triangular area with base above, approximately at the level of the sternoclavicular articulation, the rounded apex being on the plane of the second costal cartilage or lower. In some cases enlarge- ment of the thymus may be demonstrated by skiagraphy; tracheo- scopy will demonstrate the presence of thymic stenosis, but is a dan- gerous procedure in these cases. Treatment. — Since lesions of the lymphoid tissues are frequently associated with status lymphaticus or lymphatism, hypertrophied tonsils, adenoids and tuberculous lymph nodes are often found in children of this type. Individuals who show definite indications of a status condition should not be subjected to operation unless operation is imperative. Operations should be performed under local anesthesia or under carefully administered ether anesthesia, never under chloroform. 1 Status Lymphaticus and General Anesthesia, British Med. Jour., 1908, 19G. 8 114 SHOCK AND ALLIED CONDITIONS For thymic asthma with marked dyspnea due to enlargement of the thymus, thymectomy is at times indicated. It has proved efficient in a number of cases. 1 SURGICAL RISK IN ALCOHOLICS. The habitual consumption of alcohol markedly increases the risk of an operation. The risk is much greater in the chronic tippler than in one who occasionally indulges to excess. Following the prolonged use of alcohol serious organic changes occur, for example, arteriosclerosis, cirrhosis of the liver, myocarditis and nephritis. As a result of chronic lesions of this kind the diseased organs are frequently seriously affected by operations under general anesthesia. Suppression of urine, uremia, cardiac weakness, etc., may result. Although in a large proportion of cases, chronic alcoholism pro- duces in the various organs the pathological changes which favor the development of such postoperative complications, alcoholism is not always the cause. Therefore, these complications will be discussed under separate headings, in the consideration of the organs with which they are connected. There are, however, certain operative dangers and serious sequelae which are definitely and immediately dependent upon chronic alcoholism. The administration of a general anesthetic to a chronic alcoholic is not only difficult but it is dangerous. Alcoholics require a large amount of ether to secure proper relaxation; they usually breathe badly and cyanosis supervenes rapidly. As a result of the dilatation of the vessels hemorrhage from the operative wound is increased. Postoperative delirium tremens and pneumonia are of frequent occurrence. Alcoholics do not respond to stimulants as well as non-alcoholics; large doses are required, and even these are usually less effective than smaller doses in non-alcoholic individuals. The resistance of the tissues to infection appears to be diminished by chronic alcoholism. Before operations are undertaken upon alcoholic patients, a preliminary course of treatment should be enforced if possible; such a coarse will do much towards the prevention of delirium tremens. Operation should be delayed from two days to about two weeks. Alcohol should be gradually withdrawn; adequate sleep should be secured, if neces- sary by hypnotics, such as bromides or paraldehyde; simple food should be taken frequently and in abundance; the bowels should be moved freely and regularly and warm baths should be given regularly. Before operation morphine and atropine should be administered to quiet the patient and to lessen the amount of anesthetic required. 1 Cf. Parker, Surgery of the Thymus Gland, Amer. Jour. Diseases of Children, 1913, v, 89. SURGICAL RISK IN ALCOHOLICS 115 Delirium Tremens. — The shock of injury or operation not infre- quently acts as the exciting cause of an attack of delirium tremens in an individual predisposed to this condition l>y chronic alcoholism. The condition rarely occurs in periodic drinkers, hut rather in those who regularly consume a considerable amount of alcohol each day. It follows the use of whiskey more frequently than of wine or beer. The sudden withdrawal of alcohol in a person addicted to its use seems to precipitate the attack in some cases. Symptoms. — The onset of the attack is usually from one to three days after the operation or accident. It is characterised by extreme irritability, restlessness, sleeplessness and persistent incoherent talk- ing, although the patient may give intelligent answers to questions. There is marked tremor of the ringers, lips, and tongue. The bowels are constipated; the appetite is poor. If the attack progresses, the patient develops delusions of persecution, sees strange animals, insects, serpents, and other reptiles about him and in his bed. He makes violent efforts to rid himself of these, and calls upon his attend- ants for assistance. He tries to get out of bed and loudly abuses a nurse or attendant who attempts to restrain him. There are marked tremor, profuse perspiration, evidences of extreme fright, and of acute mental and physical sufferings. Yet, in spite of constant efforts to get out of bed and to resist those who are restraining him, there is no evidence of pain in the injured part, which is often used vigorously. The pulse becomes rapid and feeble and the patient exhausted. The urine usually contains considerable albumin. The exhaustion which follows the violent efforts may result in syncope and sudden death, or coma may supervene and death follow at a later period. Not infre- quently complications develop, especially pneumonia. The mortality of postoperative delirium tremens has been placed as high as 50 per cent.; the death rate is decidedly higher than when delirium tremens is unassociated with injury. If the outcome of the attack is favorable after about two to four days, in uncomplicated cases, the exhausted patient falls into a deep sleep; on awakening he feels weak and tired; his mind is clear but he has little or no recollection of what has occurred. Treatment. — The treatment of delirium tremens should begin as early as possible. The essential factors are food and sleep. An abun- dance of simple food should be given frequently and regularly. Milk. eggs and beef preparations are to be recommended. To induce quiet and sleep sedatives must be given freely until the desired effect is obtained. Sodium bromide often acts well, especially early in the attack; paraldehyde is of value since it acts quickly, although the effect is not lasting; moreover, it may increase the excitability and delirium. It may be given by mouth, oj~i v > or by rectum in larger doses. Drugs that act more slowly, such as sulphonal, gr. x, may be combined with paraldehyde to advantage. Numerous other hypnotics, as veronal, trional and chloral have been recommended. Chloral is often combined with bromides. When patients refuse to swallow, the 116 SHOCK AND ALLIED CONDITIONS hypodermic injection of £ grain of morphine with T ^ (7 grain of scopo- lamine or hyoscin hydrobromide will be found useful, also hyoscin hydrobromate in doses of T ^ to y 1 - grain. The liberal use of alcohol is usually recommended early in the attack; alcohol administered after the symptoms have fully developed certainly has no effect on the duration of the disease. Nevertheless, in many cases the asthenic condition of the patient indicates the use of stimulants. Under these conditions, alcohol may be effective, or other cardiac stimulants may be necessary. Cold baths or packs and repeated and prolonged lukewarm baths have been used with satisfactory results. They have a sedative effect, induce sleep and at times do away with the need of narcotics. The bowels should be carefully regulated; an initial dose of calomel is advisable. When a patient is so restless as to need con- stant restraint he should be secured by a jacket or by folded sheets attached to the bed, but care should be taken lest the respiratory movements be interfered with. Prophylaxis. — Prophylactic measures should be . employed after injury or operation in those who are predisposed to delirium tremens. The liberal use of alcohol is advisable; food should be given frequently and in abundance; sleep should be induced by narcotics, such as bromides; the bowels should be moved freely and regularly, and fluids should be administered by rectum or by hypodermoclysis to favor free elimination through the skin and kidneys. ACIDOSIS. The term acidosis was introduced by Naunyn to define a clinical condition which was supposed to be dependent upon the accumulation of acids in the body in sufficient quantity to interfere with normal metabolism. The usual explanation of acidosis is dependent upon the following interpretation of certain chemical changes which there is reason to believe occur in the human body. The complete oxidization of fats normally results in water and carbon dioxide. Incomplete oxidiza- tion of fats leads to the formation of fatty acids among which are B. oxybutyric acid and diacetic acid, which further oxidization converts into acetone. Fatty acids thus produced are neutralized by the alka- line bases, ammonia, sodium, potassium, calcium, etc., which combine with the fatty acids. These bases are derived from the blood to a con- siderable extent and the alkalinity of the blood is lowered in proportion to the diminution of its bases. The unneutralized fatty acids and the salts of diacetic acid are toxic. The work of Emden and others suggests that the liver plays a part in the intermediary katabolism of fats and that certain unpaired con- ditions of the liver or its blood supply cause interference with the complete oxidization of fats and therefore favor the formation of fatty acids. ACIDOSIS 117 The energy of the body is derived largely from the oxidization of carbohydrates; if carbohydrates are insufficiently supplied to the body either as a result of deficiency of ingested carbohydrates or imperfect absorption or assimilation of these substances, the store of body fat is unduly drawn upon to supply the requisite energy. "Under conditions which involve a large destruction of fat in the body, as in starvation, fevers, and especially diabetes, B. oxybutyric acid together with aceto-acetic acid and acetone are excreted in the urine. These three substances are designated as the acetone bodies and their appearance in the urine makes the condition known as acetonuria." (Howell.) Why the oxidization of fats in many of these cases does not go on to completion is explained by the fact that without sugar combustion fat never burns to C0 2 and H 2 0. But why the deprivation of sugar leads to incomplete oxidization of fats is not understood. Acidosis in Diabetics. — In diabetes there is a perverted condition of metabolism which is represented chiefly by a failure to store surplus sugar, i. e., to form glycogen, and an inability on the part of the tissues to use sugar for energy. As a result, in severe cases, the store of body fat is unduly drawn upon to supply requisite energy. This is intensified if the demand for carbohydrates is increased by exercise, operation, fright, etc. If this condition of abnormal katabolism pro- gresses to a marked degree acidosis results. When the usual symptoms of diabetes, e. g., thirst, increased appetite and glycosuria are replaced by anorexia, nausea, vomiting and gastric tenderness, or if the patient becomes unusually drowsy, his intellect dull and his mind and body readily fatigued, an acidosis should be suspected. If examination of the urine shows the presence of acetone bodies the diagnosis is verified. Acidosis is not likely to develop in mild cases of diabetes, that is, in cases in which glucose disappears from the urine on a carbohydrate free diet; on the other hand, acidosis is to be feared in cases in which glucose does not disappear on such a diet. A diabetic patient who has been secreting small amounts of acetone is prone to develop symptoms of acidosis under conditions which over- tax his powers; such as, strong mental or bodily exertion, infec- tious diseases, acute alcoholic intoxication and chloroform or ether narcosis. Diabetics are poor surgical risks not only because of the danger of acidosis, but also on account of the relatively poor reparative power of their tissues and the lack of resistance of their tissues to infection. In connection with the surgical risk in patients presenting diabetes, it is important to emphasize that ammonia estimation in a twenty- four-hour specimen of urine should always be made before operation. " Since the acid in excess of amounts that are neutralized by the fixed bases combines with ammonia and is excreted as an ammonia salt, it is evident that increased ammonia in the urine is a rough estimate 118 SHOCK AND ALLIED CONDITIONS of the degree of acidosis." 1 Two grams of ammonia always indicates an extremely bad operative risk; approximately one gram may be supported but, if possible, such a patient should receive preliminary treatment. If the ammonia is in excess of 2 1 , grams it cannot be expected that the patient will survive an operation. Patients pre- senting ammonia to the amount of H grams should be treated with repeated alkaline infusions as a prophylactic measure. It is important that this treatment should not be deferred until the development of diabetic coma. Acidosis in Norirdiabetics. — Individuals who are apparently normal may show a trace of acetone in the blood and the urine. The aceto- nemia and acetonuria are increased by fasting or a limitation of the carbohydrate intake, by reason of the incomplete katabolism of the body fats which are drawn upon. The by-products of this katabolism are the acetone bodies and if these are produced and accumulate in the body in sufficient amount, the symptoms of acidosis may develop. An anesthetic administered to an individual presenting acetonuria or symptoms of acidosis frequently aggravates the condition. To a severe degree of acidosis have been ascribed certain severe symptoms which in some cases terminate in the patient's death. (Brew'er; Brack- ett, Stone and Low; Favill.) However, it has not been proved that acidosis is the exclusive causative factor. Symptoms of Acidosis in Non-diabetics. — The patients are usually young; they present, besides acetonuria, some of the following symp- toms; headache, vertigo, tachycardia, dyspnea, nervousness and a peculiar sweetish odor to the breath. They are apt to take an anes- thetic badly and to remain stupid or unconscious for an unusually long time after the anesthetic is discontinued. Postanesthetic Acidosis.- — It has been noted not infrequently that after the administration of an anesthetic a patient has developed acid- osis. In a large majority of cases chloroform has been the anesthetic used and the condition has sometimes been termed "Delayed Chloro- form Poisoning;" 2 yet the condition has been noted in rare cases after ether. This type of poisoning has occurred most frequently in children, in whom fright, change of environment and food favor a disturbance of metabolism. A long operation, the repetition of the induction of anesthesia within a few days, high fevers, acute diseases of the stomach and intestines, inanition, stricture of the esophagus and diseases of the kidneys and liver predispose to the occurrence of acetonuria. In nearly all of the fatal cases of postanesthetic acidosis in non- diabetics the pathological findings have been reported as an acute degeneration of the liver similar to that found in acute yellow atrophy or phosphorus poisoning. 1 N. B. Foster, Diabetes Mellitus. 2 Howland and Richards believe that delayed chloroform poisoning is not due to acid intoxication. ACIDOSIS 119 Symptoms. — After operation, in mild eases the patient has a distaste for food, is nauseated and on about the fourth or fifth day vomits. These symptoms clear up under appropriate treatment. In the more severe cases, vomiting becomes persistent and there is a sweetish odor to the breath, the patient looks very sick, his face has a grayish pallor, the skin is cold and clammy, the pulse rapid and weak; the patient may sink into a condition of collapse and death may ensue. At times death is preceded by restlessness, delirium, convulsions, dyspnea, Cheyne-Stokes' respiration, cyanosis and coma. Jaundice is present in some cases. Treatment. — Prophylaxis. — In this connection Van Xoorden's dic- tum is of interest; that in the normal individual "acetonuria can in every case be prevented by the administration of abundance of carbohydrate food." Before an anesthetic is administered, the urine should be examined for acetone; if acetone is found, the urine should be tested for diacetic acid. If one or both are present operation should be delayed until the acidosis is overcome. For this purpose carbohydrates and alkaline fluids should be given freely. Sodium bicarbonate, gr. xv every four hours, should be given by mouth until the urine is distinctly alkaline. Carbohydrates should be administered by mouth, and glucose in 5 per cent, solution may be given by rectum. Before the operation a small dose of morphine should be given to reduce the amount of anesthetic required: chloroform should not be employed, except on rare occasions and then only for a short period. An enema containing 5 j of olive oil and g j of glucose, to be retained, may be given just before or after the operation. Active Treatment. — If acidosis develops after an operation alkalies and carbohydrates should be administered freely. wSodium bicarbonate, 5ss every hour by mouth or, if the vomiting is severe, a Murphy drip of 5 per cent, solution of sodium bicarbonate should be given. Hypo- dermoclysis is not to be recommended because abscess formation some- times results. Foster recommends intravenous infusion of 5 per cent, sodium bicarbonate, or 4 per cent, sodium carbonate, 200 c.c. every two hours until a liter has been given, using the salvarsan apparatus. Glucose may be given by mouth or rectum ; by mouth, as a powder or in solution; by rectum, as a 5 per cent, solution to be retained, or as a continuous drip. In severe cases, not diabetic, Foster recommends glucose in four to five per cent, solution of distilled water, giving 100 c.c. at intervals of two to four hours until the symptoms are relieved or until 1000 c.c. have been given. For severe vomiting tincture of iodine, Tfl.v in half an ounce of water in repeated doses, has been recommended. In grave cases exhibiting marked jaundice with progressive toxemia there is no treatment which offers any hope ; the condition is practi- cally the same as in other forms of acute yellow atrophy of the liver. 120 SHOCK AND ALLIED CONDITIONS CARDIAC WEAKNESS. The condition of the heart may be an important factor in the success or failure of an operation. Not infrequently operative deaths have been the direct result of pathological changes in the valves or the myocardium. Valvular disease, if uncompensated, is a contra-indication to surgical procedures, especially under general anesthesia. Failure of compensation is usually readily recognized by such symptoms as rapid and irregular heart action, dyspnea, cough, dropsy and signs of passive congestion or edema of the lungs. Valvular disease, if fully compensated, and if not accompanied by circulatory disturbances under conditions of moderate physical exertion, should not deter the surgeon from administering an anesthetic and undertaking important opera- tions. The condition of the heart muscle is of the greatest importance from a surgical standpoint. Changes in the myocardium are due to a number of causes, among which may be mentioned acute and chronic infections, exhausting diseases, nephritis, alcoholism, general arterio- sclerosis, obstruction of the coronary arteries and obesity. These may result in fibrosis, fatty infiltration and degenerative changes, especially fatty degeneration. Symptoms. — Chronic myocarditis may not give rise to any symptoms or physical signs, and the existence of cardiac weakness may not be sus- pected until the sudden development of serious symptoms during an operation. On the other hand, the pulse may be feeble, abnormally slow or fast, with attacks of arhythmia and dyspnea on exertion; the first sound may be weakened and occasionally a murmur is present. Arhythmia is said to be more serious than regular tachycardia. The walls of the peripheral arteries are frequently thickened, and hyperten- sion often accompanies a chronic myocarditis; it may be possible to recognize physical signs of general cardiac hypertrophy. In a person past the prime of life, especially in men who have led active business lives, these symptoms and signs should be sought before operation is advised. Their recognition may modify the decision as to the advisa- bility nature of an operation. In cases with myocardial changes death may occur without warning on the operating table or from slight exertion during recovery from the anesthetic. In other instances the patient may become gradually cyanosed during the operation, with increased rapidity and decreased force of the pulse beat, which does not respond to stimulation. Death may occur within a few hours. In patients predisposed to this condition the occurrence of cyanosis, not due to spasm of the glottis or bronchorrhea, especially if asso- ciated with rapid, irregular and weak pulse, demands the immediate cessation of the anesthetic and the inauguration of stimulating measures. UREMIA 121 A type of cardiac weakness which has received considerable atten- tion recently is the "myoma heart," 1 that is, cardiac weakness in women having fibromyomata of the uterus. It is supposed to be caused by toxins. The symptoms of this condition may be shortness of breath, palpita- tion, precordial distress, irregularity of pulse and frequent headaches. Fleck reported 12 deaths in 325 cases, directly or indirectly due to cardiac changes; 3 without operation (1 from embolism, 2 from myo- cardial changes (brown atrophy) ) ; 9 died at the operation or shortly afterward. UREMIA. The effect of a severe trauma, sepsis, or surgical operation requir- ing general anesthesia in individuals who have kidney disease, is often to provoke an acute exacerbation and to produce a fatal toxemia. While in the majority of instances the anesthetic is the chief cause of the disturbance, the condition of sepsis, the shock of trauma or operation, and loss of blood, may act as contributing causes by lowering the resistance of the patient. While any disease of the kidneys which impairs their function may give rise to uremia after operation, the condition known as chronic Bright's disease, associated with both parenchymatous and interstitial changes in the organs, and the cases of septic pyelonephritis which have passed the acute stage and in which the disease often exists as a latent disorder for a long period of time without symptoms, are the conditions most to be feared. As the embarrassment of the renal function in these cases is due largely to an acute hyperemia of the organ produced by the elimination of large quantities of the anesthetic, and other toxic substances generated by the anesthetic or the disease for which the operation is undertaken, the length of operation and amount of the anesthetic agent used, as well as the method of its administration, will be found to be important factors. Long exposure on the operating table with insufficient or wet covering will favor renal congestion by lowering the surface temperature. Symptoms. — The symptoms of toxemia from renal insufficiency are too well known to need description; apathy, somnolence, dry foul tongue, high-tension pulse, diminished secretion of urine, and gen- eral appearance of illness, with increase in the temperature and other evidences of wound infection, should always excite suspicion of renal trouble, and measures should at once be undertaken to promote elimination and prevent further poisoning. In these cases examina- tion of the urine will show it to be scanty, albuminous, and often bloody; casts are present and the output of solids is diminished. In the severe cases there may be absolute suppression of urine with a 1 Doane, Surg., Gynec. and Obst., January, 1912; Barrows, Amer. Jour. Surg., 1912, xxvi, 161; Fleck, Arch. f. Gynak., 1904, lxxi, 258. 122 SHOCK AND ALLIED CONDITIONS rapidly developing coma, Cheyne-Stokes respiration, convulsions, and death. Treatment. — Early treatment is often of great value in this con- dition, and lives are frequently saved by judicious management. The administration of large quantities of water by the mouth, saline rectal irrigations, intravenous infusions, hot-air baths, cathartics, digi- talis, nitroglycerin, dry cups over the loins, milk diet, and general stimulating measures are to be employed. HEAT-PROSTRATION. Gibson has called attention to the fact that individuals under general anesthesia are apparently very susceptible to the prostrating efl'ects of heat. Patients undergoing surgical operations during hot weather, especially if preceded by a long period of fasting, not infre- quently exhibit symptoms of profound weakness accompanied by a rapid, feeble pulse, exceedingly high temperature, and mental con- fusion or delirium. The symptoms sometimes appear immediately after the operation, always within a few hours, and long before septic influences could produce such effects. In a case recently under the observation of the writer the removal of a pharyngeal growth was fol- lowed in a few hours by a rise of temperature to 106° F., with a pulse of 1()0. Under appropriate treatment the pulse and tempera- ture gradually fell to normal without evidences of sepsis. In another and fatal instance, an easy and short laparotomy was immediately followed by a rise in temperature which in twelve hours reached 109.4° F. Treatment. — The treatment of these cases should be by cold water and stimulation. Placing the patient on a rubber sheet and sprinkling with cold water from an ordinary garden sprinkling pot, every two or three hours, will often produce a marked improvement in the symptoms. Ehrenfried calls attention to the importance of prophylaxis. He states that when the operating room has a temperature of 90° F. or over, a large ice-cap should be held by the anesthetist against the patient's occipital region. HEMORRHAGE. Hemorrhage, or the escape of blood from the vessels, occurs as a result of trauma, surgical operation, or disease. Traumatic hemorrhage may be external, if the loss of blood occurs from a wound of the skin or soft parts; internal, or concealed, if the bleeding occurs into one of the cavities of the body; or subcutaneous, if it takes place into the soft tissues beneath an unbroken skin. A hemorrhage is said to be primary when it occurs at the time of the trauma; intermediate or recurrent, when it occurs after a few hours — twelve to forty-eight; secondary, when it occurs after a few days — HEMORRHAGE 123 from two to the complete healing of the wound. Bleeding may occur from the arteries, veins, or capillaries, or from all combined. Arterial hemorrhage is generally recognized by the bright scarlet color of the blood, and by the fact that it occurs in jets synchronous with the pulse; venous hemorrhage, by the steady flow of dark-colored blood which is easily controlled by pressure; capillary, by the general oozing of blood from a large area of divided tissue. Extensive subcutaneous hemor- rhages, if arterial, give rise to large pulsating tumors — false aneurism*; if venous, to large collections of blood — hematomata — which do not pulsate (unless situated immediately over an artery), and in which the sensation of fluctuation can be obtained. Ecchymoses, or "black and blue marks," represent subcutaneous hemorrhages too small in amount to form distinct tumors. Hemorrhage from disease may occur in the brain — cerebral apoplexy — where it is generally the result of endarteritis; from the nose — epis- taxis — where it results from congestion or ulceration of the mucous membrane; from the lung — hemoptysis — which is often the earliest symptom of tuberculosis; from the stomach — hematemesis — caused by new growth, ulcer, passive congestion, or intense inflammation; from the bowels — melena; from tumors, acute or chronic ulceration, or congestion; from the urinary organs — hematuria — from new growth or disease of the kidney, bladder, prostate, or urethra. Alarming hemorrhages occasionally occur from slight and insig- nificant traumata, due to an hereditary condition known as hemo- philia. Little is known regarding the etiology of this condition other than the fact that this tendency to hemorrhage is transmitted from one generation to another. Such individuals are called bleeders, and they should not be subjected to surgical operation except under con- ditions of extreme emergency. Symptoms. — A moderate loss of blood in a vigorous, healthy indi- vidual produces no symptoms other than a feeling of slight weakness. If the amount lost is greater, there is a feeling of giddiness, dyspnea on exertion, mental confusion, and a disposition to faint. In severe cases there may be in addition thirst, air-hunger, partial blindness, ringing in the ears, and suspended consciousness. Accompanying these symptoms there are pallor, coldness of the extremities, a moist, clammy skin, rapid, sighing respiration, and restlessness. The pulse is rapid, feeble, thready, irregular, and compressible; the temperature is sub- normal; there is great physical weakness; nausea and vomiting may occur; the pupils are dilated, the eyes often fixed, and the counte- nance expressionless. In continued hemorrhage these symptoms are all exaggerated, consciousness is lost, tremor or convulsions may be present, the pulse becomes imperceptible, the heart fluttering, and death speedily occurs. Da Costa states that death may be expected if one-half the volume of blood is lost. It often occurs with much smaller hemorrhage if the loss is rapid or accompanied by shock from other causes. 124 SHOCK AND ALLIED CONDITIONS Treatment. — Nature's method of arresting hemorrhage is by the formation of a clot in or about the wound of the vessel. This forms first around the opening, then extends into the lumen of the vessel, and if undisturbed causes its permanent closure, ("lotting occurs early in wounds of the smaller vessels, especially the veins, which collapse more readily than the arteries, and prevents a serious loss of blood. In wounds of the larger vessels, however, the force of the blood- current prevents the formation of a clot until the vascular tension is greatly lowered, often after the patient lias fainted. The lessened force of the blood current, which results partly from the diminished volume of blood in the vessels and partly from vasomotor paresis from cerebral anemia, together with a condition of greater coagulability of the blood apparently present under these circumstances, finally results in the formation of coagula in the mouths of the vessels and arrests the hemorrhage before death occurs. In wounds of the larger trunks the Fig. 38. — Rubber tubing applied to arrest hemorrhage. patient is quickly exsanguinated and death results before nature*s processes have begun. In the treatment of hemorrhage from any vessel of considerable size only one method should be employed by the surgeon, and that is, to expose, isolate, and securely ligate the bleeding artery or vein. No other method gives the same degree of safety to the patient or the same feeling of security to the surgeon. Many circumstances, however, may be present which will prevent the carrying out of this plan, and under these conditions other methods must be employed. The appli- cation of a tourniquet above the bleeding point is perhaps the method most generally employed for the temporary arrest of severe hemorrhage from an injured limb. In the absence of a regularly constructed tour- niquet, the best material for this purpose is a medium-sized piece of rubber tubing (Fig. 38), large enough to avoid cutting the skin and sufficiently elastic to exert considerable pressure when snugly applied. This should be made to encircle the limb, should be well drawn out, and tied or securely held by forceps, care being taken to avoid pressure HEMORRHAGE 125 on the nerve trunks. In the absence of rubber tubing any strong material may be used, as a flannel or muslin bandage, a strip of folded cotton or linen cloth, or even a skein of worsted. These should be tied tightly about the limb and additional pressure exerted by twisting with a stick I Fig. 39). Digital pressure at the bleeding point or over the artery supplying the part will often be serviceable in temporarily arresting a hemorrhage until other and more permanent means can be employed. Mechanical compression by means of sponge or gauze packing applied to the bleeding point and firmly held by a bandage is serviceable, especially in venous bleeding or capillary oozing. Hyper- flexion at certain joints, as the knee and elbow, with or without a pad of gauze or cotton at the angle of flexion, will often serve to compress the artery and arrest hemorrhage. The flexion should be maintained by bandage, and can be borne only for a short time. Elevation of the limb causes at once a diminution in the amount of blood lost, and in connection with other temporary measures will often be successful. The application of hot water or ice to a bleeding part is often em- ployed with success in venous and capillary oozing. Certain chemical agents, called styp- tics, have the power of producing firm clots, and are occasionally employed, especially in the throat and nasal cavities. Of these the persulphate of iron in powder or solution (Monsel's solution or salt) has been most frequently employed. Tannin, alum, anti- pyrin, cocaine, and adrenalin are also exten- sively employed, the two last chiefly on mucous membranes. Strong hydrogen perox- ide has been found by the writer to be useful in controlling capillary oozing in wounds, and also in mucous membrane hemorrhages, and has the advantage of being as well a powerful antiseptic agent. Acetone is ex- tremely useful to control bleeding from the very friable tissue of ulcerating metastatic carcinoma such as is found secondary to carci- noma of the breast; it may be applied to small areas by inverting a test-tube containing the fluid over the site to be treated, allowing the acetone to be in contact with the bleeding area for a few minutes, or gauze may be saturated with acetone, covered with rubber tissue, to prevent rapid evaporation, and applied to the involved urea with firm pressure. The actual cautery will occasionally be found of value in arresting hemorrhage, expecially from the cut surface of bone, or the oozing from divided inflammatory tissues. Of the methods applicable directly to the bleeding vessel, ligature, torsion, acupressure, and suture may be employed. Fig. 39. — Spanish windlass. 126 SHOCK AND ALLIED CONDITIONS Ligature. — The wound should be held apart by retractors, and sufficiently enlarged to obtain a good view of the bleeding point; the vessel should be separated from the surrounding tissues and clamped. If an artery has been completely divided, both ends should be found, clamped, and ligated. If it has sustained a lateral wound, it should be clamped above and below the wound, divided, and each end securely ligated. If a vein is found to be the source of the hemorrhage, the bleeding end should be tied. In small lateral wounds of large and important venous trunks the wounded edges should be grasped by a clamp and a lateral ligature applied (Fig. 40). In friable inflamed tissues, in sloughs, in the dura mater, and often in disease of the vessel walls, the application of a ligature by means of a curved needle passed around the vessel through the surrounding tissues is to be recom- mended. When possible, absorbable ligature material should be employed. For small vessels and in wounds which are expected Fig. 40. — Lateral ligature. to heal primarily ordinary sterile catgut is to be preferred. For the large arteries, and often in wounds which are left open or are expected to suppurate, chromicized catgut or silk may be employed. Torsion. — Twisting the divided end of an artery will often arrest bleeding by rupture and inversion of its inner coats. It has the advan- tage of leaving no foreign material in the wound, which in plastic operations may occasionally prevent accurate coaptation. Small vessels may be successfully closed by simply making two or three revolutions of the clamp. In large vessels the surrounding tissue should be removed and the exposed artery held gently by a forceps while the end is clamped and twisted. Acupressure. — An old method seldom used at present. It consists in introducing a needle or hare-lip pin through the skin under the vessel and applying pressure by means of a figure-of-eight ligature or by twisting the pin over the vessel and forcing it again into the tissues. HEMORRHAGE 127 Suture of a Wounded IY.s-.sv7. — "Wounds in large venous trunks, too large to be closed by lateral ligature, may often be sutured with fine silk. The sutures should be introduced with a fine round needle, and should include all the coats of the vessel. In arterial wounds the problem is far more difficult, owing to the fact that the blood-pressure is higher, and the fact that the sutures are apt to tear out by the alternating dilatation and contraction of the vessel wall. In the majority of instances, however, if the arterial wall is in a normal con- dition, carefully introduced fine silk sutures will be successful in closing a longitudinal wound. In more extensive wounds, division of the vessel and end-to-end anastomosis by the method of Carrel should be em- ployed. In cases of abnormally high arterial tension, and in cases of thickened and calcareous arterial walls, closure of small wounds may be accomplished by the use of an aseptic rubber adhesive plaster, which is wrapped around the vessel and allowed to remain imbedded in the tissues. The writer demonstrated the feasibility of this plan by a series of animal experiments which were reported to the New York Surgical Society in 1904. 1 In the treatment of recurrent and secondary hemorrhages pressure may be tried if no important vessels are involved and if the bleeding is moderate. In all other cases the wound should be opened and the bleeding vessel secured. This in recurrent or intermediary hemorrhage is generally easy; but in secondary hemorrhage, where the bleeding is usually due to necrosis of the vessel wall from infection of the surround- ing tissues, considerable difficulty may be experienced, and ligature of the main arterial trunk above the wound may be indicated. The treatment necessary to overcome the systemic effect of a severe hemorrhage consists in absolute rest in bed with the head low- ered and the trunk and extremities elevated. The heart should be stimulated by whiskey, strychnine, digitalis, and atropine; and the volume of blood increased by direct transfusion or by a large intravenous infusion of normal salt solution. Heat should be applied to the surface of the body by means of warm blankets and hot-water bottles; fluid food should be taken by the stomach or given by the rectum. In severe cases with recurring syncope death can sometimes be averted by applying elastic bandages to all four extremities, thereby forcing all available blood into the vessels of the trunk and brain. The after-treatment should consist in rest, an abundance of nutritious food, with iron, arsenic, and large quantities of beef-juice, bovinene, or beef peptonoids. Calcium chloride or lactate in full doses is highly recom- mended for persistent capillary hemorrhages; also before operation when a strong tendency to hemorrhage is known to exist. The treatment of special hemorrhages associated with visceral and other traumata will be considered elsewhere. 1 Annals of Surgery, December, 1904. CHAPTER VII. SURGICAL TECHNIC. ASEPSIS AND ANTISEPSIS. Before the discovery of the relationship between micro-organisms and wound infection, and the general acceptance of the germ theory of infectious diseases, little or no effort was made by surgeons to employ more than ordinary cleanliness in their surgical work. The region of the wound rarely was washed, the surgeon generally carried his dress- ings in his pocket, his needles and sutures in his medicine-case, and washed his hands after rather than before operation. Practically all wounds were infected, fully 90 per cent, suppurated, postoperative pus was supposed to be a normal accompaniment of repair, and the death rate from pyemia, septicemia, tetanus, and erysipelas after severe traumata and surgical operations was very high. The discovery in 1867, by Sir Joseph Lister, of the bacterial cause of wound infection, and the demonstration by him of the results obtained by his new method of wound treatment, inaugurated a reform in surgical tech- nic which was immediately taken up by surgeons in all parts of the world. During the past twenty years these methods have been considerably modified and improved, and have resulted in the modern perfected aseptic and antiseptic technic now almost universally employed by surgeons. Two methods of wound treatment are in general use at present, the antiseptic or germ-killing method and the aseptic or germ-excluding method. Both methods have for their object the rendering of the wound sterile or free from pathogenic micro-organisms. The neces- sity for these methods depends upon the now generally accepted fact that micro-organisms are practically everywhere present; no object can be regarded as free from them until it has been subjected to a process of sterilization. Sterility is something more than cleanli- ness. A freshly laundered pocket-handkerchief lying in a dainty bureau-drawer may be said to be clean, but it is not sterile, and would not be suitable for a wound dressing until it had been subjected to dry or moist heat at the temperature of 212° F. or above, for half an hour at least, or had been soaked in some strong antiseptic solution. Any subsequent contact with an unsterilized object would immediately destroy its sterility and render it again unfit for a wound dressing. The antiseptic method was first used by Lister, and consists in removing as far as possible pathogenic organisms from the wound ASEPSIS AND ANTISEPSIS 129 of the patient and the hands of the operator and his assistants by vigorous scrubbing with soap and water, and afterward killing the remaining germs or those subsequently introduced into the wound, by the generous employment of solutions of chemical disinfecting agents, as carbolic acid, mercuric chloride, etc. The instruments, sponges, gowns, towels, dressings, etc., are all to be rendered sterile before being brought into contact with the wound area. This method, formerly universally employed, is now used chiefly in infected cases and in those in which the more perfect aseptic method cannot be successfully carried out. The aseptic method is the more modern, and is a decided improve- ment over the preceding when it can be perfectly carried out. It does away with the necessity of employing antiseptic agents by insuring absolute sterility of everything which may by any possibility be brought into contact with the wound. It has, however, two weak points, the skin of the patient and the air of the operating- room, neither of which can with certainty be rendered sterile. Practically, however, these factors are of little moment, as infec- tion rarely occurs which cannot be traced to other sources of con- tamination. The aseptic method is applicable to all cases in which the wound area is free from infection at the time of operation, when the operator can have the advantage of a well-equipped operating-room and trained assistants. When these cannot be had, or when errors of technic occur, antiseptic measures must also be employed. The methods of skin disinfection, and the preparation of the instru- ments, sponges, dressings, gowns, sheets, towels, etc., are the same in both methods, and are as follows: Preparation of the Patient. — When possible a full bath should be taken the day before the operation, followed by shaving the wound area and as much of the surrounding skin as will be exposed on the table. The part should then be scrubbed with soap and hot water for two minutes, after which a soap poultice should be applied for severa hours. The morning of the operation the parts should again be scrubbed with soap and water for from three to five minutes, a sterile towel or mass of fluffed gauze being employed by a nurse or assistant after thorough disinfection of the hands and after having drawn on a pair of sterile rubber gloves. A wet bichloride dressing (1 to 5000) should then be applied. This should be removed on the operating- table and the part scrubbed for one minute, afterward douched with alcohol, ether, bichloride solution, and sterile water. Another good method is as follows: Shave the part to be operated on the evening before operation; wash with benzine to thoroughly dry the surface, paint with 3.5 per cent, tincture of iodine; allow to dry and apply a dry sterile gauze dressing. On the operating-table the gauze is removed and a fresh coat of 3.5 per cent, tincture of iodine is applied and allowed to dry thoroughly and remain on for three minutes. 9 130 SURGICAL TECH NIC The excess of iodine may then be removed by alcohol. For an emer- gency case the part is shaved dry and painted with 7 per cent, tincture of iodine. This should be allowed to dry for eight minutes, then to prevent its burning the excess of iodine is removed by alcohol. This should be done by mopping the surface, not by rubbing. The wound area should then be surrounded by a sterile sheet or sterile towels which cover all parts of the body and operating-table likely to be touched by the surgeon, his assistants, or instruments. Preparation of the Operator, His Assistants, and the Nurses. — All should be clothed in sterile gowns or suits, the head covered with a cap, face and mouth protected by gauze or a helmet of cotton cloth, and the sleeves rolled up above the elbows. The hands and arms should be prepared by scrubbing with soap and frequent changes of hot water for five minutes, a sterile nail-brush being employed. Particular attention should be given to the region of the nails, which should be previously cleansed with a pointed orange-wood stick or other nail- cleaner. After scrubbing for five minutes a paste may be made in the hand by moistening a mixture of equal parts of chlorinated lime and washing-soda with a little hot water. When this becomes slightly warm and free chlorine gas is given off, the paste should be thoroughly rubbed on the hands and arms, and afterward completely removed by bathing in sterile water and mercuric chloride. Or after scrubbing as above with soap and water, the hands may be immersed in alcohol for two minutes. Freshly sterilized rubber gloves should then be drawn on the hands and worn by all participating in the operation. The rubber gloves may be sterilized by boiling or by placing in live steam for twenty minutes at 10 lbs. pressure, and dried in vacuum autoclave. Preparation of the Instruments, Silk, Silkworm Gut, Silver Wire, etc.— These are all rendered absolutely sterile by boiling for five minutes in a 1 per cent, solution of sodium carbonate (anthrax and subtilis spores are killed by boiling water in two minutes). The instruments should afterward be transferred to sterile water, as the sodium solu- tion renders them too slippery to be easily held. Knives, scissors, and needles are rendered dull by frequent boiling. These may be sterilized by immersion in pure carbolic acid, afterward rinsing in alcohol and sterile water. Preparation of Suture and Ligature Material. — The materials used for sutures and ligatures are silk, silkworm gut, catgut, chromicized cat- gut, kangaroo tendon, horse hair, and silver wire. Silk, silkworm gut, horse hair, and silver wire may be sterilized by boiling, or by subjecting them to live steam of a temperature of 212° F. or above for one hour. Catgut may be sterilized by the following four methods: 1. Place the catgut in a glass flask of ether, shake frequently for six hours, then change to a flask of absolute alcohol and shake fre- quently for six hours, then in a flask of 10 per cent, solution of carbolic ASEPSIS AND ANTISEPSIS 131 acid in absolute alcohol and shake at intervals for six hours more, after which store in absolute alcohol until used. 2. After treating with ether and alcohol as above, boil in alcohol under pressure for thirty minutes. 3. Iodine catgut is prepared by Bartlett in the following manner: Cut strands of suitable size and wind into small coils. Suspend the coils in liquid petrolatum heated on a sand bath to 212° F. for twelve hours, then raised to 300° F., after which the coils are transferred to a solution composed of 1 part of iodine flakes to 110 parts of Columbian spirits. 4. Roosevelt Hospital method: Raw catgut is immersed in the following solution: Hydrarg. bichloride, gr. xv Acid tartaric, gr. lxxv Ether, Columbian spirits, aa Oj. — M. No. 1 should be allowed to remain in the solution six hours, No. 2, eight hours, No. 3, twelve hours, No. 4, sixteen hours, No. 5, twenty hours; after which the catgut is stored in Columbian spirits. Many other methods are in use, including that by cumol and forma- lin. Where cumol is employed the catgut is subjected to very high heat, 350°; this is the method employed by most commercial houses. It requires a special apparatus and considerable experience to properly prepare the catgut. Chromicized catgut may be prepared by soaking the catgut in a solution of chromic acid, made by dissolving 30 grains of the crystals in 1 pint of a 5 per cent, aqueous solution of carbolic acid, and allowing it to remain in the solution from six to twenty-four hours, after which it should be wound on a frame and thoroughly dried, and then sterilized by any of the above methods. Preparation of Gauze Dressings and Sponges, Cotton Gowns, Sheets, Towels, etc. — These are best sterilized by live steam under pressure, but they may be sterilized by dry heat. One of the modern steam autoclaves (Fig. 41) should be used if possible. By means of this the live steam is introduced to the articles to be sterilized (1) after they have become heated so there is no water of condensation and (2) after all air has been removed from their interstices by means of a vacuum pump. They may be subjected to the action of live steam under high pressure for any length of time, but thirty minutes at 20 lbs. pressure is sufficient to kill all bacteria and their spores. It is also possible prior to the removal of the sterilized goods to exhaust the steam and thoroughly dry them. By means of the Arnold sterilizer (Fig. 42) dressings may be subjected to the action of live steam, but not under pressure. This kills the fully developed pus-producing bacteria, but not the spores. A fairly satisfactory improvised sterilizer may easily be made out of an ordinary wash-boiler. Take two bricks, place them in 132 SURGICAL TECH NIC the bottom of the boiler, pour in about two quarts of water, and then cover the bricks by two or three long strips of thin board laid length- wise. On these place the various bundles of sheets, towels, gowns, bandages, dressings, etc., to be sterilized. Put the cover on the wash- boiler and place it on the kitchen range for thirty minutes, after which the materials will be ready for use. When this cannot be obtained, freshly laundered sheets, which are practically free from germs, or clean towels soaked in bichloride solution (1 to 1000), can be used, and the sponges and dressings can be boiled for two minutes and allowed to cool before using. Marine sponges are rarely used in aseptic surgery on account of the difficulty in their sterilization. They should be freed from sand and dust, bleached, and kept in a 1 to 20 solu- tion of carbolic acid for several weeks. All instrument-trays, sponge basins, and other glassware should be kept scrupulously clean, sterilized in a Fig. 41. — Steam autoclave. Fig. 42. — Arnold sterilizer. large steam sterilizer, or immersed in a large tub of bichloride (1 to 1000) for thirty minutes, and afterward rinsed in sterile water. Irrigating solutions should be made with distilled or boiled water. Normal salt solution may be made by dissolving K)0 grains of chemic- ally pure sodium chloride in 32 ounces of water and boiling for two minutes. If it is to be used for intravenous infusion, it should be filtered. General Management of an Operating-room. —While each surgeon should arrange the duties of his assistants and the general details of BANDAGING 133 his operative technic to suit his own ideas and purposes, a few general rules should he observed in all well-regulated operating plants. The operating stall' of a large general hospital should consist, in addition to the operating surgeon, of two sterile assistants and two sterile nurses. In addition to these there should be one or two extra attendants, nurses or orderlies, to assist in moving the patient, to regulate the position of the operating table, handle the electric lights, cautery, irrigating cans, etc., and to assist the anesthetist. The first assistant should stand opposite the operator, sponge and clamp vessels; the second assistant should handle the retractors; the chief operating nurse should have charge of the instrument-tray, the ligature and suture material; the assistant nurse should handle the sponges, towels, sheets, and pads. Each assistant should thoroughly understand his or her duties and should follow the operator and antici- pate his wants. As far as possible, talking should be avoided by those participating in the operation as it has been repeatedly demonstrated that infection may occur by contamination of the wound area by minute quantities of mucus or saliva from the mouths of talking operators or assistants. To avoid this possibility and also to prevent any loose hairs or dandruff dropping into the wound, face masks and hoods of gauze or cotton cloth should be worn by all the assistants and nurses. Good team work on the part of the operator and assistants is the essential factor in perfect operating-room technic. Loud talking and angry criticism on the part of an operator generally defeats his object by rendering the assistants nervous and hasty in their various duties, which, in turn, always favors the occurrence of technical errors. The rough handling of the tissues, the tearing apart of anatomic structures, bruising the wound edges by forcible retraction, and the inclusion of large masses of tissue in hemostatic ligatures are to be avoided as favoring infection. Other things being equal, the best results will be obtained by the surgeon who performs his operation in the shortest time and with the minimum of exposure and trauma to the tissues. BANDAGING. Bandages are used in surgery chiefly to hold in place surgical dress- ings and splints; they are also employed to exert pressure on certain parts and thereby to relieve congestion, to promote absorption of extravasated fluids or exudates, to prevent edema, to support weak- walled vessels, as well as to give protection and support to injured limbs and joints. The materials used for bandages are gauze, muslin, crinolin, rubber, flannel, canton flannel, and fabrics impregnated with plaster of Paris, starch, dextrin, and other hardening substances. For holding dress- ings in place, the muslin or gauze bandage is commonly employed; for supporting varicose veins, applying pressure to a limb or joint, the 134 SURGICAL TECHXIC rubber or flannel bandage is used; while to insure fixation of a broken limb or injured joint, the plaster of Paris, starch, or dextrin bandage is to be recommended. Roller Bandages. -If the part to be bandaged is of even size through- out, as the upper arm or trunk, the free end of the bandage is laid upon the part and held in place by the left hand, while the roller is carried Fig. 43. — Ascending spiral bandage. (Wharton.) by the right hand around the part to be bandaged in such a way that the second turn will hold the first firmly in place. Each revolution of the bandage covers at least one-half of the last turn. When the upper limit of the bandage is reached, the end is pinned to the layer beneath (Fig. 43). If the part to be bandaged is conical, as the leg or forearm, the spiral reversed bandage is applied, in which each turn is made to fit snugly to the limb by being turned upon itself, as seen in Fig. Pig. 44. — Method of making reverses. (Wharton.) 44; or the figure-of-eight bandage is employed, in which the lower loops of bandage are snugly and evenly adapted to the limb, and as the bandage a>cends they eventually cover the more loosely applied upper loops (Fig. 45). In applying a bandage to the groin or shoulder, the spiea is employed, beginning on the limb and making a figure-of- eight around the limb and trunk, as seen in Fig. 4(3. In bandaging BANDAGING 135 the thumb or one of the fingers the free extremity is covered with the spiral/ reversed ; and when the base is reached the spica is used, the upper loop of which encircles the digit and the lower loop the hand and Fig. 45. — Figure-of-eight bandage of leg. (Park.) wrist (Fig. 47). In bandaging the knee, the figure-of-eight is used, the first turn being taken around the joint opposite the middle of the patella, after which the loops alternate, one being applied above and Fig. 46. — Ascending spica bandage of the groin. (Wharton.) Fig. 47. — Spiral bandage of the finger. (Wharton.) the next below the first turn (Fig. 48). In bandaging the head, one or two loops are made to encircle the head, passing from the frontal region just above the eyes around the occipital protuberance; a figure 130 SURGICAL TECH NIC Fig. 48. — Figure-of-eight bandage of the knee. (Wharton.) Fig. 49. — Transverse recurrent bandage Fig. 50. — Recurrent bandage of the head, of the head. (Wharton.) (Wharton.) Fig. 51. — Recurrent bandage of a stump. (Wharton.) BANDAGING 137 of-eight bandage is then applied in a transverse direction, beginning just above one ear and carrying the first turn over the centre of the vault to the opposite ear; then a number of turns are taken between these two points alternately in front of and behind the first until the entire vault is covered. The loops made by reversing the bandage just above each ear are firmly held until all the transverse turns are made, and finally secured by three or four encircling turns around the forehead and occiput, safety-pins being finally introduced to hold all in place (Fig. 49). The folds covering the vault may also be made longitudinally if desired (Fig. 50). In bandaging an amputation-stump, make one or two circular turns around the circumference of the stump, then a number of turns at a right angle to these, inclosing the extremity, and holding these Fig. 52. — Modified Velpeau dressing. (Wharton.) in place by a circular or reversed spiral from the extremity upward until a joint or some bony protuberance is covered to hold it in place (Fig. 51). The Modified Velpeau Bandage. — To apply the modified Velpeau bandage for holding the arm securely to the chest wall. Place the hand on the opposite shoulder; take two or three turns of a wide roller bandage around the thorax, including the arm; then pass the bandage from the free axilla behind to the fixed shoulder, passing over this shoulder from behind forward; carry the bandage around the point of the elbow and then upward behind the same shoulder over its summit downward in front to the free axilla, then circularly around the chest, alternating these turns until the entire arm and chest are included (Fig. 52). All of these methods may be modified to meet special indications. 138 SURGICAL TECHN1C Fig. 54. — Breast binder. BANDAGING 139 Triangular or Folded Handkerchief Bandage. — The triangular or folded handkerchief bandage is made by folding a square piece of muslin or gauze into a triangle. This can be applied over a bulky dressing of the hand or amputation-stump by placing the base of the triangle at right angles to the limb and folding the apex over its extrem- ity, and securing it by wrapping the two extremities of the base snugly around the limb and tying them. This bandage may also be employed on the head. Fig. 55. — Breast binder. T-bandage. — The T-bandage is used for dressings applied to the perineum, the horizontal arms encircling the trunk, the perpendicular arm passing between the thighs from behind upward and fastened to the front of the body portion (Fig. 53). Many-tailed Bandage. — The many-tailed bandage is useful for almost any part where dressings are frequently changed. It is par- 140 SURGICAL TECHNIC Fig. 56. — Jaw bandage. Fig. 57. — Triangular sling. BANDAGING 141 ticularly serviceable when a firm abdominal binder is required and in breast amputations. Two-tailed Jaw Bandage.— The two-tailed jaw bandage is useful for holding the lower jaw firmly against the upper, as in fractures of the lower jaw or in wounds of the chin (Fig. 56). Sling. — The sling, to support the forearm and arm, is made by folding a large piece of muslin into a triangle. Place the two extrem- Sling and chest binder. ities of the base line around the neck and allow the forearm to rest in the loop (Fig. 57). The Sling and Chest binder.— This is a very useful bandage for fixing the arm to the chest, and is used in fractures of the clavicle and humerus, injuries to the shoulder and elbow. Place one extremity of a triangular sling in place around the neck, flex the elbow and place the forearm across the chest, then apply a chest binder including the upper arm, and fix with safety-pins, after which the other extremity 142 SURGICAL TECHMC of the sling is folded around the forearm and carried upward around the neck and tied to the one already in place; fasten all these layers together with safety-pins (Figs. 58 and 59). Plaster-of-Paris Bandages. — Plaster-of-Paris bandages are used whenever a fixed stiff dressing is required for protection or to limit mobility. They are made by rubbing plaster of Paris into the meshes of a gauze or crinolin bandage. The part should first be covered with a layer of sheet wadding, cotton, or lint. The plaster bandages are then placed in cold water. When the bandage is thoroughly soaked it should be grasped at each end and gently squeezed toward Fig. 59. — Sling and cheat hinder. the centre and applied over the layer of wadding. Care should be taken to apply the layers evenly, and in general the figure-of-eight should be used on a conical part rather than the reversed spiral, as the wet bandage when reversed is apt to roll itself into a hard cord, which may produce subsequent discomfort. Good plaster will set or harden in a few minutes. These dressings are removed by cutting or sawing through the plaster down the front or along one side. In thick casts this is often difficult, and can be made easier by moistening with a strong solution of mercuric chloride, dilute hydrochloric acid, or hydrogen peroxide. WOUND Dh'KSSI.XCS 143 WOUND DRESSINGS. Clean, freshly made wounds are best dressed with sterile dry gauze, which is simply held in place by a bandage. The dressing should be large enough to extend well beyond the wound-limits, and secured firmly enough to prevent being displaced and exposing any part of the wound. The use of thin silver foil next to the wound or a layer of gauze wet with a 1 to 100 solution of for- malin will serve to prevent stitch infection from Staphylococcus epidermidis albus. If there is reason to suppose that the wound is infected, provision should be made for drainage by leaving the wound partly open, and packing with gauze im- pregnated with sterile albolene, by the in- troduction of a rubber drainage-tube (Fig. 60), or by the use of a thin strip of folded sterile rubber protective tissue. If the wound is a deep one, or in one of the body cavities, or if an abundant fluid discharge is expected, a double rubber drainage-tube may be employed, or, especially in the abdominal cavity,the cigarette drain will be found useful. This consists in a roll Fig. 60. — Rubber drainage-tube. W: Fig. 61. — Cigarette drains. 144 SURGICAL TECH NIC of gauze covered by thin rubber tubing or rubber protective tissue (Fig. 61). In making these the gauze should not be rolled too tightly, but loosely so that wound secretions may drain out through it. Wet Dressings. — Infected or open wounds are often treated by wet dressings. Several layers of gauze are wet with some antiseptic solu- tion and placed next to the wound; this is covered with oiled silk or rubber tissue to prevent too rapid evaporation, and held in place by a roller or many-tailed bandage. Wet dressings should be frequently opened and more of the solution added. Of the solutions most used, mercuric chloride, 1 to 5000 to 1 to 1000; aluminium acetate (1 part of alum, 25 parts of lead acetate, and 500 parts of water) ; carbolic acid, 1 to 500 to 1 to 100; Thiersch's solution, made by dissolving 1 part of boric acid and 6 parts of salicylic acid in 500 parts of water; and myrrh wash, made by adding 1 part of tincture of myrrh to 12 parts of water. The latter is very useful in foul suppurating wounds. Abscess cavities and long suppurating sinuses should be dressed once or twice daily, irrigated with some antiseptic solution, as a weak solution of tincture of iodine, and allowed to heal from the bottom. Such cavities, if indolent, should be packed with gauze soaked in balsam of Peru or "red wash/ 5 which is a mixture of 2 parts of zinc sulphate and 100 parts of tincture of lavender in 500 parts of water. LIGATURES. Wounded vessels should be clamped and ligated. If possible, an absorbable ligature should be used. Sterile catgut is the material to Fig. 62.— Reef or flat knot. Fig. 63. — Granny knot. Fig. 64. — Surgeon's knot. be recommended, the smaller sizes for small vessels, larger sizes for medium-sized vessels, and medium or heavy chromicized catgut for METHODS OF WOUND CLOSURE 145 the larger arteries. When sterile catgut cannot he had, silk should be used. If neither can be obtained, ordinary linen thread boiled for ten minutes will answer the purpose. The reef or square knot (Fig. 62), the granny knot (Fig. 03), and the surgeon's knot (Fig. 64) are the ones generally employed. The Ballance and Edmunds knot is highly recommended in the ligature of large arteries. Two strands of floss silk are passed around the vessel and the first half of a knot tied in each separately; then both strands are taken together and the last half of the knot tied as one. METHODS OF WOUND CLOSURE. If the wound is superficial, aseptic, and there is no tension, the divided edges of the skin can be approximated and held by a few inter- rupted sutures (Fig. 65), care being taken that the edges of the wound Fig. 65. — Interrupted su- ture. (Park.) Fig. 66. — Continued su- ture. (Park.) Fig. 67.— Chain-stitch suture. are in exact apposition, and not folded inward by drawing the suture too tight. Tight suturing also favors marginal necrosis and infection by interfering with the circulation. Silk, silkworm gut, horse-hair, silver wire, or wound clips are to be preferred to catgut for cutaneous sutures for the reason that catgut swells, seals the minute opening through which it passes and thus prevents capillary drainage. The continuous suture is largely employed in closing cutaneous wounds (Fig. 66), also the locked stitch (Fig. 67) or the mattress suture (Fig. 68). The continuous mattress suture, or Gushing suture, is employed by many in intestinal work (Fig. 69). When considerable force is needed to bring the wound edges together, a few deep sutures intro- duced at some distance from the wound margin, relieve the tension on cutaneous sutures. Strong silk or silkworm gut is the best material for the purpose. In deep ivounds and amputation-stumps it is often desirable to bring the muscles and fascial layers together to avoid dead spaces, which 10 146 SURGICAL TECH NIC allow accumulation of blood and other fluids and favor infection. This is accomplished best by the introduction of a few deep catgut sutures. In closing abdominal wounds it is desirable to unite the differ- ent structures separately, in order to prevent a subsequent hernia; the peritoneum should be drawn together with a continuous suture of catgut, the muscular and aponeurotic layers with chromicized cat- Fig. 68. — Mattress suture, interrupted. Fig. 69. — Cushing suture. gut, and the skin with silk or silkworm gut. Many surgeons employ the throughrand-through suture of silkworm gut or silver wire, including all layers. In the upper zone of the abdomen this method may be employed, as hernias rarely occur in this region. It is to be advised also whenever the condition of the patient demands a speedy termina- tion of the operation, as it requires much less time than a layer suture. The subcuticular suture has been extensively employed of late to avoid stitch infection and to render the scar-line less noticeable. It consists in the use of fine silver wire or silkworm gut with a full- Fig. 70. — Subcuticular suture. (Wharton.) curved Hagadorn needle. The needle pierces the skin just beyond one extremity of the wound and emerges just within the cut below the cutis. From this point the needle is passed through the subcuticular tissues first on one side and then on the other until the opposite extremity is reached, when the needle again pierces the healthy skin just beyond the wound angle (Fig. 70). When the suture is drawn tight the two edges CATHETERIZATION 147 of the wound are approximated. Experience has shown, however, that these scars eventually become as wide as the others, and also that stitch infection can practi- cally always be prevented by the use of silver foil or formalin gauze over the cu- taneous wound. The use of metal skin clips is a rapid and convenient method of skin closure (Fig. 71). Cutaneous approximation without sutures by means of strips of sterilized zinc oxide adhesive plaster, suggested Fig. 71.— Metal skin clips and forceps. by Lilienthal, is occasionally employed. The advantages are that ample drainage space is provided, the skin is not pierced, strangulation of the marginal tissue is avoided, and the chances of infection greatly reduced. CATHETERIZATION. Catheterization, or the introduction of urethral instruments, in the female is generally easy. If a soft-rubber catheter is employed, the tip is well lubricated with sterilized vaselin, or lubrichondrine, and introduced within the external meatus, after which the catheter is easily passed into the bladder. If a silver or glass instrument is used, it should be introduced with the curved tip pointing upward. In catheterizing the female, the instrument should be introduced under the direct vision. The nurse should stand on the patient's right. The labia should be separated by the thumb and index finger of the left hand, and the catheter introduced directly into the meatus without coming in contact with any other part. In the male, catheterization is more difficult owing to the length of the urethra, its subpubic curve, and the fact that the curved portion of the canal is fixed by strong ligamentous structures. The subpubic curve in the adult male urethra corresponds to an arc of a circle three and one-quarter inches in diameter; an solid urethral instruments, therefore, should have a curve corresponding with this. As in the female, soft -rubber and gum- elastic catheters or bougies are easily introduced into the normal male urethra and bladder by simple pressure, the penis being held at a right angle to the body. In introducing a solid silver catheter (Fig. 72) or sound, the surgeon should stand on the patient's left, the penis should be grasped by the forefinger and thumb of the left hand, and drawn upward on the abdomen; the instrument, well lubricated, should be held in the right hand, the shaft being parallel with Poupart's ligament. As the sound glides into the canal the shaft should gradually be carried toward the median line and elevated, and when the point of the sound 148 SURGICAL TECH NIC reaches the prostatic portion, the shaft should be exactly in the median line of the body and at a right angle with it. Firm pressure should then be made by the right hand over the root of the penis, and with the left, the handle should be gently depressed between the thighs. This allows the beak to follow the natural curve of the urethra and to pass into the bladder. If the calibre of the urethra is narrowed or deviated by stricture, periurethral exudate, or enlargement of the prostate, the flexible gum-elastic olivary, coude or long prostatic catheter should be Fig. 72.— Metallic catheter. Fig. 73.— Prostatic catheter. Fig. 74. — Flexible catheters. Fig. 75. — Mercier's coude catheter. used (Figs. 73-75). All urethral instruments should be sterilized before introduction, and the region of the meatus disinfected by careful wiping with a pledget of cotton wet with a 1 to 1000 solution of mercuric chloride, (ilass, metal, and soft-rubber catheters should be sterilized by boiling; gum-elastic or silk catheters by immersion in a solution of bichloride of mercury or by formalin vapor. If the urethral mucous membrane is infected, it should be irrigated with bichloride solution (1 to 10,000) or potassium permanganate (1 to 4000). In all catheteriza- tions, the use of sterilized rubber gloves is to be recommended. DIRECT TRANSFUSION OF HU)OD 149 DIRECT TRANSFUSION OF BLOOD. The direct transfusion of blood from one individual to another is indicated in cases of severe hemorrhage, grave secondary anemia, severe toxemia from sepsis, gas poisoning or acid intoxication, hemo- philia, congenital melena, chronic icterus, and other conditions asso- ciated with lessened coagulability of the blood. It is also indicated to improve the physical condition of a debilitated patient about to undergo a surgical operation. It may also be of value to increase the normal resistance of an individual in certain cases of sarcoma or other malignant processes, or to render him immune to certain infectious diseases. While the advantages of direct transfusion of blood have been recognized for centuries, and various more or less ingenious instruments have been devised to accomplish this end, the operation had been prac- tically abandoned by surgeons for the reason that it rarely succeeded, and in not a few instances disastrous results followed their attempts. The chief reason for failure was that in the older methods an attempt was made to pass the blood of the donor through a rubber, glass, or metal tube to the veins of the recipient. This almost invariably resulted in clotting, which quickly obstructed the flow. The demonstration by Carrel that clotting could be eliminated by end-to-end suture of vessels in such manner that intima was brought into direct contact with intima, paved the way for a more rational technic. Certain preliminary precautions should be taken whenever possi- ble in order to prevent possible disastrous accidents. Certain tests should be made on the blood of the donor, c. g., a Wassermann, and between the blood of the donor and the recipient, e. g., the agglutina- tion and hemolysis tests. In the case of *v~ brothers and sisters or parents and children these may be safely omitted, but in cases where Fic „ 6 no such relationship exists they should, where sion cannula. (X2.) possible, be carried out. Crile has devised a simple cannula (Fig. 70), having a slightly conical hollow point with two grooves on the outer surface. A short handle projects from one side of the cannula, by which it is held. The technic of the operation is as follows: The recipient and donor are placed on two tables and their arms prepared in the usual manner. Under local anesthesia the radial artery of the donor is exposed for about two inches and ligated at its distal extremity. A temporary clamp is next placed on its proximal end and the artery divided near the ligature. The redundant layer of adventitia is drawn downward and cut off, and the vessel threaded through the lumen in the cannula. The lumen of the vessel is then grasped by three equidistant mosquito forceps and drawn backward 150 SURGICAL TECH NIC over the distal end of the cannula, forming an inverted cuff with intirna outward. This is held in place by a ligature of fine silk placed over the second groove. The vein of the donor is prepared in the same man- ner, its lumen expanded by three small clamps, and drawn over the inverted arterial cuff on the cannula. The two are secured in place by a second ligature placed over the first groove, which securely holds the two vessels in contact. The temporary clamps are next removed and the blood allowed to flow into the vein of the recipient. The flow at first is often slow, owing to the contraction of the artery from exposure. The application of wet compresses at a temperature of from 108° to 112° F. will generally bring about relaxation of the arterial walls, and a vigorous flow of blood follows, which causes marked pulsa- tions in the vein. Elsburg has also devised a cannula somewhat similar to that of Crile. It has a lumen adjustable by means of a screw. This on the whole is an improvement on Crile's cannula. The above technic, while not particularly difficult to one who has had an opportunity of rehearsing the operation either upon an animal or the cadaver, is often attended by certain embarrassments, especially in young children. Recently Kimpton has devised a cannula and tube which he coats with paraffin or Vincent's mixture. (Stearin, 1 part; paraffin, 2 parts; vaselin, 2 parts.) This tube consists of a flask containing 150 to 250 c.c. which has a special neck (Figs. 77 and 78). He exposes a vein in donor and recipient, fills the tube from the donor and then rapidly injects under low pressure the blood into the exposed vein of the recipient. INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION 15] Linderman found that if the blood was transmitted rapidly, within a minute or two, that it could be abstracted from the donor's vein by means of a glass syringe and injected into the veins of the recipient, and did not clot or cause any untoward results. He devised special cannula; to fit veins of various sizes and employs two dozen Kecord 20 c.c. syringes, rapidly changing and rinsing them as they are used. Fig. 78 Hooker and Satterlee have devised a method by which they collect the blood in 50 c.c. glass flasks either coated with paraffin or a weak solution of hirudin to prevent clotting; and by an ingenious cannula designed to prevent the contamination of the blood with tissue juices, they transmit it rapidly and safely. They find that with such flasks several minutes may safely elapse before coagulation occurs. The latest improvement in the technic of blood transfusion is that suggested by Lewisohn. He found that the addition of 0.02 per cent, of sodium citrate to human blood prevents coagulation for an indefi- nite period. His plan is to draw the blood from the donor by means of a simple cannula, mix it with the sodium citrate, and inject into an exposed vein of the recipient. Fig. 79. — Funnel and tube for intravenous injection. INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. Intravenous infusion of normal salt solution has advantages over all other means of rapidly increasing the circulating medium. It is accomplished by means of an irrigating jar or funnel, a rubber tube, and metal cannula (Fig. 79). Any superficial vein of sufficient 152 SURGICAL TECHNIC size to receive the cannula will answer. Usually the median cephalic or basilic vein is chosen. This is exposed by a short incision, cleared, and ligated. Above the point of ligature an incision is made into the vessel, the cannula introduced and held by a second ligature. From 1 to 5 pints of normal sterile salt solution at a temperature of from 110° to 118° F. may be slowly introduced according to the necessities of the case. Care should be taken that the tube and cannula are filled with the solution before the cannula is introduced, to avoid entrance of air. In an emergency a satisfactory infusion apparatus may be made from an ordinary tin or glass funnel, a piece of rubber tubing, and a glass eye-dropper. Normal salt solution can be made by adding 130 grains of chemically pure sodium chloride to 1 quart of sterile water. The addition of adrenalin chloride to the solution is often a valuable aid in the treatment of shock, aiding in the contrac- tion of the splanchnic vessels and the re-establishment of vasomotor control. HYPODERMOCLYSIS. Large amounts of fluid may be added to the circulation by intro- ducing salt solution into the subcutaneous connective tissue. This is easily accomplished by an irrigator, tube, and large aspirating needle. After sterilization of the apparatus and skin of the patient the needle is introduced beneath the skin of the abdomen, thorax, thigh, buttock, or in females beneath the mammary gland, and from 1 to 2 pints of normal salt solution allowed to infiltrate the tissues. This is rapidly absorbed, and the result though slower is often satis- factory. Oftentimes, especially in marasmic infants, a larger number of caloric units may be introduced in this manner by adding glucose to the solution. The same result often may be accomplished by prolonged irrigation of the rectum and colon by means of the Kemp tube. CHAPTER VIII. ANESTHESIA. The term anesthesia signifies a condition of insensibility to pain. An anesthetic is any agent which induces this condition. Anesthetics are divided into general anesthetics and local anesthetics; the former when properly administered produce insensibility to pain over the entire body, accompanied by loss of consciousness; the latter produce insensibility over a limited region only, not accompanied by uncon- sciousness. General anesthesia is induced by various chemicals introduced into the blood, either in vapor form, by way of the respira- tory tract, by way of the colonic mucous membrane, or in liquid form directly into a bloodvessel. The general anesthetics in common use are ether, chloroform, and nitrous oxide. Local anesthesia may be induced by the introduction of certain drugs subcutaneously into the spinal canal or into a limited distribution of bloodvessels. The local anesthetics most frequently used are novocaine and cocaine, although eucaine, tropacocaine and stovaine may be employed. Previous to the discovery of ether, nitrous oxide and chloroform, the only means which surgeons possessed to mitigate the sufferings of patients was the local application of cold and the administration of opium and alcohol. The sufferings experienced by those who were obliged to undergo surgical operations limited the employment of the art of surgery to cases of dire necessity, and led surgeons in their operative procedures to sacrifice everything to speed. The adaptation, for purposes of surgical anesthesia, of ether in 1842 by Long of Georgia, and independently of him in 1846 by Morton of Boston; of nitrous oxide in 1844 by Wells of Hartford; of chloroform in 1847 by Simpson of Edinburgh, led to a complete revolution in surgical procedure. When it was appreciated that by the use of these agents complete insensibility to pain could be safely produced and maintained during a protracted surgical operation, many distressing conditions formerly untreated were brought to the surgeon for relief, and as surgeons gradually became more deliberate in their work, a higher perfection in technic resulted. General Anesthesia. — General anesthesia is employed chiefly to render surgical operations painless, to diminish suffering during parturition, to produce muscular relaxation for the reduction of fractures, dislocations and occasionally hernias, and for the purpose of thorough physical, especially pelvic, examination. Occasionally it is employed to give relief in painful surgical disorders such as the passage of a renal calculus or gall stone, or in cases of intense neuralgia. 154 ANESTHESIA General anesthesia is contra-indicated in cases of uncompensated valvular disease of the heart, in myocarditis, in advanced arterio- sclerosis, in the newborn and in the very old, and in conditions of very severe shock. It is to be distinctly understood that no one method of anesthesia or any one anesthetic is indicated in all surgical cases. The choice should be determined by the conditions in each individual case. The wise surgeon recognizes the advantages of the several anesthetics, and decides which anesthetic is best adapted to meet the needs of the individual patient. Much harm is done by the routine, thoughtless use of one anesthetic for all cases. Thus, in one patient ether may light up a quiescent pulmonary tuberculosis, in another patient chloroform may cause an acute exacerbation of a chronic nephritis, in still another nitrous oxide may cause a cerebral hemorrhage where marked arteriosclerosis with high blood-pressure is present. Nitrous Oxide. — Priestley discovered the gas in 1772. Sir Humphrey Davy appreciated its anesthetic properties, for in 1800 he had a wisdom tooth extracted while under its influence. He then made the remark- able prediction, "Since nitrous oxide seems capable of destroying physical pain it may be used in surgical operations where there is no great effusion of blood." Strangely enough his prophecy was not fulfilled until Horace Wells in 1844 began to use it in his dental prac- tice. Ether and chloroform superceded it, however, in surgical work and it is only within the past decade that it has come to be perfected and adopted as a general anesthetic, not alone, but in combination with oxygen. Since 1900 the greatest advances in the field of anesthesia have been made in the administration of nitrous oxide and oxygen, and of nitrous oxide, oxygen and ether. This combination is recog- nized as the best form of anesthesia, considered from every standpoint, available at the present time. Credit for perfecting the necessary apparatus and the technic of administering it is due to such men as Hewitt, Teter, Gwathmey, Connell and Boothby. The indications for nitrous oxide-oxygen anesthesia are: presence cf complicating pulmonary or renal disease, sepsis, diabetes, cachexia, shock. The contra-indications are the extremes of youth and old age, uncompensated valvular lesions, advanced arteriosclerosis, with high blood-pressure, and the presence of obstruction to the air passages, such as enlarged tonsils, adenoids, pharyngeal or laryngeal growths. The advantages of this anesthesia when properly given far outweigh the disadvantages. The advantages are the non-irritating, odorless gas, the absence of excitement during its induction, the non-toxicity both during and after anesthesia, the absence of distressing after- effects such as severe nausea and vomiting, stupor, headache, thirst; finally, the absence of postoperative pulmonary and renal complications. The disadvantages are its greater cost and the more expensive and NITROUS OXIDE 155 complicated apparatus needed in its administration; also the great difficulty in securing deep anesthesia and muscular relaxation. As administered today by any one of several apparatuses, certain principles are essential. Nitrous oxide should never be used without oxygen except for very short operations. There should never be any obstruction to the air passages. Cyanosis should constantly be Fig. 80 avoided except in the early stages of induction. There should be a regular and visibly controlled flow of both nitrous oxide and oxygen, at whatever rate desired, at a uniformly low pressure, never over a few ounces, into a rebreathing bag which should be connected with the face piece by a wide, but short, connecting tube. The mouth piece should fit accurately to the face and should be air tight. There should be an efficient and easily controlled method of adding ether 15fi ANESTHESIA vapor to the nitrous oxide mixture when necessary. The gases should be heated to body temperature at the point of delivery to the patient. The apparatus recently devised by Luke combines all these essential features and is by far the most compact and efficient of the many apparatuses now in use. (Fig. NO.) It is advisable in the majority of cases, except in children, to precede the administration of this form of anesthesia with a moderate dose of morphine and atropine; this places the patient in a quiet, neutral state of mind and provides for the relief of pain when the patient regains consciousness immediately after the anesthesia is stopped — the usual dose being morphine -g- grain, atropine ttg grain, hypoder- mically, one-half hour before the beginning of the anesthesia. Better muscular relaxation is secured if the area of incision is locally anes- thetized with novocaine in \ to \ per cent, solution. Co-operation on the part of the surgeon in advising the anesthetist when a deeper narcosis is desired at the time of incising the peritoneum or other sensitive tissues, assures a smoother anesthesia. The correct procedure is as follows : The apparatus being previously tested and ready, and the patient having been given instructions to breathe normally, and having been quietly reassured, the face piece is applied comfortably; air only is given at first, then the air vent is closed and the nitrous oxide is turned on. As soon as the patient begins to have deep respirations and shows beginning cyanosis the oxygen is turned on in small amount, and as soon as muscular relaxation is obtained the face piece is firmly secured to the head and sufficient oxygen is added to insure a pink color without reducing the complete anesthesia. The average ratio of nitrous oxide to oxygen during the first hour of anesthesia is six liters of the former to one liter of the latter; the proportions of the gases more nearly approach each other as the operation is prolonged. The symptoms of overdosage of nitrous oxide are: cyanosis, or when abundant oxygen is being used with it, a death-like pallor, stertorous breathing, the onset of excessive secretion of mucus, and shallow respirations. These symptoms, to- gether with any respiratory obstruction, are the danger signals, and should be immediately treated. Addition of ether vapor is indicated whenever a mixture of nitrous oxide and oxygen, with a proportion of the latter sufficient to keep the patient's color pink, has not produced a sufficient muscular relaxation to meet the demands of the surgeon. A few moments of addition of ether vapor until this relaxation is secured is usually sufficient; the remainder of the operation can then be carried out with a return to the nitrous oxide-oxygen mixture. Ether. — Ether was first discovered in the sixteenth century. It was first used medicinally in 1795 in treating asthma. In 1818 Faraday observed that "when the vapor of ether mixed with common air is inhaled it produces effects very similar to those occasioned by nitrous oxide." Crawford W. Long of Athens, Georgia, having ETHER 157 observed the anesthesia produced during "ether frolics," a prevalent amusement, first used ether as an anesthetic for a surgical operation in 1842. Pie did not publish his observations until Morton had, quite independently, demonstrated ether anesthesia in 1846 in the amphitheatre of the Massachusetts General Hospital in Boston. Stages of Ether Anesthesia. — Properly administered, especially with the modern improved methods of nitrous oxide-ether sequence, the stages of ether anesthesia are seldom seen, for the patient passes smoothly into surgical anesthesia. When given alone, however, and in a certain number of patients no matter what the method used, four stages may be noted. First Stage. — The stage of confusion, or light anesthesia, is char- acterized by a sense of giddiness, mental confusion, deepened and irregular respirations, increased blood-pressure, pulse full and bounding, flushed skin, increased salivation, slight sense of choking. If the vapor is given in greater concentration the glottis closes and the patient struggles to rid himself of the cone. Second stage, or stage of excitement, is marked by a loss of conscious- ness accompanied by laughter, crying or unintelligible talking. As anesthesia deepens there occur tonic spasms of the muscles, especially of the larynx and the jaw. Pupils are dilated, but react to light. Cyanosis may be present. Blood-pressure is high. Pulse is slow and bounding. The patient may choke and vomit, or have a violent fit of coughing. There may develop a tremor of all the muscles. This is the stage that is avoided by careful induction of the anesthesia, especially with the nitrous oxide-ether sequence. Third Stage, or Stage of Surgical Anesthesia. — When this stage is reached, and not until then, the patient is ready for the operative procedure. It is characterized by muscular relaxation; regular, deep respirations; normal or slightly flushed color of the skin; pupils normal in size and reaction; absence of vomiting, coughing, and phonation; pulse full, regular, 80-100 in rate. Fourth stage, stage of overdose or poisoning, is characterized by shallow respirations; cyanosis, or dusky pallor; feeble, irregular pulse of low pressure; dilated pupils which do not react to light; dry, immobile eyeballs; cold, clammy skin. The signs of a return to light anesthesia, or the second stage, after surgical anesthesia has been reached, must be most carefully watched for and differentiated from those of deepening anesthesia, those of the fourth or dangerous stage. These signs of returning consciousness, in the order of importance to the observing anesthetist, are : increasing muscular rigidity, first and most easily noted in the tightening of the relaxed lower jaw; weak, shallow respirations; lachyrmation with movements of the eyeballs; attempts to swallow and vomit, pallor of the skin; dilated pupils which react to light. Unless these signs, singly or in combination, are immediately heeded, and more ether administered, the patient will begin to cough and vomit, move on 158 ANESTHESIA the table, and cause an interruption of the surgical procedure. The surgeon will be rightfully annoyed, the anesthetist covered with confusion. Caution. — Ether in liquid or vapor form is exceedingly inflammable. It should never be used in the presence of or proximity to a flame. The actual cautery should never be brought near the mouth or nose of a patient under ether anesthesia. Fig. 81. — Esmarch inhaler. Methods of Administering Ether. — These may be divided into the open and the closed methods. In the former, the patient does not rebreathe the vapor he has exhaled; in the latter a variable amount of rebreathing occurs because of the closed apparatus used. The Open Method. — The two chief methods are the so-called drop method where ether is dropped onto layers of gauze spread over a wire frame placed over the mouth and nose (Fig. 81); and the cone Fig. 82. — Ether cone: newspaper and towel. method, or partially open method where ether is added in varying amounts and at irregular intervals to a gauze sponge placed at the top of a cone, usually made with a cuff of newspaper covered with towel or muslin (Fig. 82). The drop method is the safest of all methods where ether alone is administered. It is less apt to cause the excite- ment stage, and because of the large amount of air mixed with the ether the dangerous fourth stage is seldom reached. It is indicated ETHER 159 in children and in patients enfeebled from any cause. It is at times difficult to use with alcoholic or stout patients because of the difficulty in concentrating the ether vapor. In such cases the closed method, or, where a closed apparatus is not available, the cone method is indicated. The procedure in giving drop ether is as follows: Over a wire mask of the Esmarch type, but large enough to cover nose and mouth, place six to ten layers of surgeons' gauze, or a double layer of stockinette material. Clamp this in place with the wire collar. Moisten a towel folded to a strip four inches wide. Cut out the top of the mouth of an ether can. Cut a small groove in the cork, place in it a wick of gauze or cotton and insert the cork with the wick into the mouth of the ether can so that the ether will drop at the rate of two or three drops a second. Having completed these preliminaries, the patient is quietly reassured and urged to breath naturally and quietly. Make sure there is no loose article in the patient's mouth such as false teeth or chewing gum. The mask is placed over the nose and mouth and the patient breathes air a few times. He is told that the ether will be added slowly, and, drop by drop, it is allowed to fall on the gauze above the mouth. After a few seconds and when the patient's breath- ing is regular, the damp warm towel is placed around the top of the mask, leaving an area of uncovered gauze an inch square. As the patient becomes more accustomed to the ether the rate of the drop is increased. As soon as the respirations deepen and the skin flushes, the ether is dropped on rapidly until the patient's muscles relax and he enters the third stage. If the drop is so regulated that choking and coughing do not occur, the second, or excitement stage, can be avoided. As soon as the third stage is reached the drop is slowed, enough only being added to keep the patient's jaw relaxed and the breathing regular. The Closed Method. — There are many apparatuses named after as many anesthetists for carrying out this method which is really the nitrous oxide-ether sequence. All of these have in common a face piece, with rubber cushion, above this a cylinder fitted with valves for regulating the flow of nitrous oxide and ether, and above this a rubber bag for rebreathing. Thomas Bennett, of New York City, first introduced this method of giving the gas-ether sequence, and his apparatus is shown in Fig. 83. The technic for giving this sequence is as follows: Inflate the rubber cushion on the face piece, but not too tightly. Place a gauze strip in the ether chamber so that it is filled loosely with gauze. Make sure no threads or loose ends project between the valve surface. Pour three or four drams of ether into the gauze in the ether chamber. Close the ether chamber so that the patient will not smell the ether. Fill the gas bag with nitrous oxide but do not overdistend it. Having completed these preliminaries outside, enter the room, quietly reassure the patient and advise him to breathe naturally. Make sure there 100 ANESTHESIA are no loose bodies in the mouth. Place the mask quietly over the patient's mouth and nose. Let him breathe air a few times. Turn on the gas (if the bag is over distended the rush of gas will frighten the patient). Have the patient breathe out through the exhaling valves several times to rid his lungs of oxygen. Then turn on the rebreathing valve and if necessary add more gas to the bag from the cylinder. If the face piece and valves are air tight, after eight or ten respirations the breathing will become rapid, deep and slightly stertor- Fig. 83. — Bennett inhaler for gas and ether. ous and the patient loses consciousness. At this point begin turning on the ether valve, very slowly at first. If the patient chokes or shows any catch in his breathing, turn off the ether, give nothing but nitrous oxide for a few respirations and again begin gradually with the ether. By the time the ether valve is on to its limit, the patient should be in full surgical anesthesia. After that, ether is added to the ether chamber in dram doses every two minutes, more or less, according to the age and size of the patient. INTRATRACHEAL AND ENDOPHARYNGEAL INSUFFLATION 161 When properly given, the advantages of the nitrous oxide-ether sequence are the avoidance of subjective sensations of choking and distress of the first stage and the struggling or cyanosis of the second or excitement stage; much less ether is used, a saving usually of a quarter to a half of the amount used in the drop method; the rapidity of the induction of surgical anesthesia, the patient usually reaching this stage in from two to four minutes. The Cone Method. — The gauze sponge at the top of the towel cone is sprinkled with ether, the cone is held two or three inches above the mouth of the patient and is gradually lowered over the mouth and nose as the ether is tolerated and breathing deepens. More ether is added until the stage of surgical anesthesia is reached, when only enough is added to continue the anesthesia. The advantages of this method are its simplicity; the disadvantages are the greater frequency and degree of excitement stage because of the concentrated ether vapor, the intermittent addition of concen- trated ether vapor with the danger, in unskilled hands, of reaching the fourth, or overdose stage. Anesthesia by Intratracheal and Endopharyngeal Insufflation. — Intratracheal Insufflation. — Meltzer and Auer first described this method in 1909. They discovered that proper exchange of air or of ether vapor and air in the lungs can be accomplished by a continuous stream of vapor passing in one direction. Their apparatus, and the more elaborate ones since devised by Elsberg and Janeway, possess the following features: Air, or oxygen, is pumped through a tube connected with a mercury monometer and a bottle or jar contain- ing ether, into the trachea. The three conditions essential to success are: (1) the tube passing into the trachea must be of a size less than one-third the diameter of the trachea, (2) the stream of ether vapor and air or oxygen must be interrupted five to eight times a minute to permit the escape of carbon dioxide from the alveoli of the lung, (3) the pressure of the air-ether vapor must not exceed 20 mm. of mercury. Indications for Intratracheal Insufflation. — (1) In thoracic surgery it prevents the collapse of the lung when the thoracic cavity is entered by maintaining an intra-alveolar positive pressure. (2) In operations on the head and neck where it is desirable to have the anesthetist away from the field of operation. (3) In operations on the mouth and nasopharynx and larynx where there is a probability of aspirating blood or septic fluids. The stream of air and ether continually escaping from the larynx blows out any fluid or particles that might enter the larynx. (4) Insufflation may be used with air or oxygen alone as a method of artificial respiration, as in severe morphine or opium poisoning. The only disadvantages of this method are its limitation to operative cases in a hospital, and, what is most important, the difficulty and trauma frequently present during the introduction of the catheter into the larynx. 11 162 ANESTHESIA Endopharyngeal Insufflation. — Dr. Karl Connell in 1912 perfected this method and with it determined the accurate percentages of ether necessary for surgical anesthesia when given by the vapor method either endopharyngeally or endotracheally. His is the most scientific work that has ever been done in anesthesia. To quote from Dr. Connell's description of the method: "The delivery is established after full surgical relaxation has been secured by face mask methods. . . . The essential feature of this pharyngeal method is that a volume of air is insufflated by positive pressure into the lower pharynx, a volume sufficient to provide entirely for each inspiration without any air being inhaled by nose or mouth and a volume bearing a known per- centage of ether vapor in the greatest dilution which will hold that patient evenly and safely anesthetized for the operation in hand. The delivery is accomplished by preference through two catheters inserted one through each nostril a distance, on the average, of 12 cm. The catheters selected for the adult are size 18, F, soft rubber, velvet-eye, with accessory eyelet. These are attached to a Y-metal delivery tube with bent prongs for convenience of placement, to prevent angulation and to hold the catheters in place. This Y-piece is attached to the forehead with adhesive. The volume insufflated is such as entirely to supply the needs of inspiration without extraneous dilution. This requires 18 litres of air per minute for the average adult; into this is vaporized the ether." Connell was the first to establish scientifically the accurate per- centages of ether necessary for surgical anesthesia when given by the vapor method either endopharyngeally or intracheally. After analyzing 600 insufflation anesthesias in the Roosevelt Hospital he plotted charts from a composite of 300 anesthesias in which careful records were kept of ether percentages in relation to the stage and degree of the anesthesia. Connell summarizes the essentials of endopharyngeal anesthesia as follows: 1. The ether tension in the arterial blood to the sensorium is the determining factor of anesthetization. 2. The tension is established by maintaining in the alveolar air during preliminary narcosis an ether content of from 30 to 45 per cent. by weight to air under conditions at sea level, an equivalent in pressure of from 119 to 182 mm. of mercury. During the early stage of anesthesia, from the first twenty to forty minutes, the tension must be maintained by percentages, scaling from 26 down to 15 per cent. After the establishment of anesthetic saturation of the body it is maintained at about the latter percentage, the equivalent of an ether pressure of 48 mm. in the alveolar air. 3. These figures probably hold for the entire animal kingdom, the variable factors seen in ordinary etherization being these: (1) The rapidity with which the entire body is brought to complete anesthetic saturation as determined by the efficiency with which the ether tension in the alveolar air is maintained by fresh delivery, by INTRATRACHEAL AND ENDOPHARYNGEAL INSUFFLATION 163 diffusion and by tidal movement; (2) the rapidity of blood circulation; (3) the bulk of the particular body to be saturated and the capacity of that body for storage and destruction of the ethyl radical. 4. The zones of anesthesia above and below this saturation or anesthetic tension point are already well established for man. With Fig. 84. — Connell's anesthetometer. absolute certainty as to the outcome, man may be placed in an ether atmosphere of the percentage of ether or vapor pressure required to produce deep, medium or light anesthesia. 5. The zone of surgical relaxation, i. e., an ether pressure of 45 to 50 mm. is a zone for many hours devoid of danger by ether intoxication. 164 ANESTHESIA The anesthetometer is an apparatus for the automatic measuring and mixing of vapors and gases used to maintain anesthesia (Fig. 84). The apparatus consists: (1) of a gas meter as the measuring and mo- tive mechanism; combined with (2), an ether reservoir from which volatile liquid is fed in accurately adjusted amounts; into (3), a vapor- izing chamber; which is combined (4) with a trip-valve by which gases in any quantity may be mixed in accurate percentage. By the use of this apparatus that accuracy of dosage in the admin- istration of gaseous drugs so long deemed necessary for liquids and solids is secured. By the use of the anesthetometer, particularly in the intratracheal and intrapharyngeal delivery, the dosage of gaseous anesthetics becomes automatic, yet under the continuous observation and control of the operator. Thus efficiency and safety in prolonged anesthesia are secured and the shock and sequelae of ether anesthesia are largely eliminated. Finally, it may be confidently expected that by the accumulation of accurate data such as this instrument makes possible, anesthesia by pulmonary absorption will be placed on such a scientific basis as accurate determination of dosage alone can secure. Chloroform. — In March 1847 Flourens in Paris announced that chloroform had an anesthetic action on animals analogous to that of ether. As a result of this discovery Sir James Y. Simpson, of Edin- burgh, introduced chloroform in his obstetrical cases and it soon, and for many years afterward, replaced ether in England and on the Continent. Chloroform is the most dangerous of the general anesthetics in common use. Hewitt says, "It would seem that we have in chloro- form a drug which is a powerful protoplasmic poison, which when given in toxic quantities leads to the death of the organism not because it paralyzes respiration — for were it merely a respiratory depressant, artificial respiration would be invariably successful in averting death — but because, as recent researches have shown, it markedly depresses the circulation." The exact nature of the paralyzing action as regards the part of the circulatory apparatus affected is not yet determined. It is a well-recognized fact, however, that the margin of safety between surgical anesthesia and overdose is far narrower than in ether or nitrous oxide. Indications. — 1. Obstetrical cases in which there is no evidence of toxemia of pregnancy. In pregnancy the heart is hypertrophied and the sphincters are active; moreover, full surgical anesthesia is not required. 2. In the very young and very old, especially as an introduction to ether. 3. In diseases of the respiratory system. 4. In presence of high blood-pressure and aneurysm. 5. In operations involving the respiratory tract, and the brain; also where the actual cautery is to be used around the face. CHLOROFORM 165 0. In tropical countries and high altitudes it is indicated, for ether evaporates too readily. Contraindications. — 1. Weak, anemic, septic or cachectic patients. 2. J n status lymphaticus. 3. In minor surgery, where a safer anesthetic is available. 4. In all operations where the patient is in the sitting posture. 5. In diabetes and nephritis. After-effects. — The immediate after-effects are fewer and less dis- agreeable than with ether, but the late effects, so-called acidosis, as evidenced by presence of acetone and diacetic acid and sugar in the urine, indicate serious metabolic disturbances with degenerative changes in the parenchymatous organs, especially the liver. The Administration**— The drop method is now universally used and is the only one that is recommended in cases where chloroform is indicated. Before starting the anesthetic certain precautions are necessary. The patient should lie in a horizontal position; there should be no constriction of the waist or neck; the chloroform to be used should be of guaranteed purity and unexposed to light or to air previous to the administration. It should be dropped, never poured, from the bottle. It should be kept stored in brown bottles. To prevent burning of the face, the lips, nose and cheeks should be covered with a thin layer of vaseline or cold cream. The eyes should be covered with gauze or a handkerchief. The mask should be of the Esmarch wire frame variety, covered with two layers of gauze or stockinette. Plenty of air should always be guaranteed with the chloroform vapor. Inasmuch as it is in the early stages of chloroform anesthesia that the accidents occur, particular care should be used in the induction. The mask (Fig. 74) should be held one or two inches above the face; two or three drops of chloroform are dropped on the gauze and in a few seconds two or three more. The mask is then lowered over the nose and mouth and as the patient breathes regularly three or four drops are added every ten seconds. By the end of two minutes the rate should be twenty to thirty drops every minute. If the patient holds his breath, stop the drops and lift the mask. After the patient has relaxed, surgical anesthesia should be maintained with half the amount that was necessary at the time full surgical anesthesia was induced. The operation should never begin before the third stage or surgical anesthesia is reached. This requires four to ten minutes from begin- ning of induction. During this stage the jaw is relaxed, as are all the muscles, the respirations are regular and full, the pulse slows down to normal rate, and the skin loses its high color. The respiration and pulse are the most important signs and should be carefully watched. Shallow or irregular respirations, an irregular pulse or a pulse below 50, and extreme pallor are danger signals, to be heeded immediately by raising the mask. A few drops of ether given at this time will usually restore the previous normal condition of the patient. 166 ANESTHESIA Intravenous Anesthesia. — In the last decade considerable work has been done in an effort to produce a uniform and safe anesthesia by introducing solutions of drugs directly in the bloodvessels. Although this has been done in the arteries the disadvantages and difficulties are too great to make it practical. Intravenous anesthesia has been successfully carried out especially in the European clinics. Burch- hardt reports a series of 250 intravenous ether anesthesias with very favorable results. Kummel reports 130 cases and strongly recommends this form of ether anesthesia in selected cases. Kiimmel believes that the cases of thrombophlebitis with embolism reported by Kuttner, Clairmont and Denk, were due to improper technic in giving the ether intravenously. Federoff of Petrograd reports several hundred cases of intravenous hedonal anesthesia with favorable results. Burch- hardt has used isopral intravenously in several hundred cases. It is the concensus of opinion that ether is safer than hedonal or isopral for intravenous injection, inasmuch as the dose is more easily controlled, is safer and is more rapidly eliminated through the respiratory tract. Kummel recommends it for the following groups of cases: Head, face and neck cases. In cases that have become greatly reduced or depleted from long-continued disease or repeated hemorrhages the intravenous saline infusion that is used as the vehicle for the ether acts as a stimulant to the heart and keeps up blood-pressure throughout and after prolonged anesthesia. The ether can be given in much more accurate dosage based on actual measured amounts of ether per kilo of body weight. The inflow is easily controlled. The toxic dose is no more difficult to combat than with inhalation ether, inasmuch as the excretion in both cases is dependent on alveolar interchange of gases. The dangers are thrombosis of the vein and embolism. Kummel claims this is entirely avoidable by the use of the continuous flow of saline. The latter is a distinct disadvantage in prolonged anesthesia, as the tissues become edematous with the saline content of the blood. The technic as described by Kummel is as follows: All patients from the twentieth to sixtieth year are given a dose of morphine' i grain, scopolomine y^y grain before operation. In partial anesthesia the patient is placed on the operating table, the eyes are covered and under aseptic precautions the median basilic vein is exposed and the cannula introduced as for a saline infusion. In order to avoid clotting as much as possible a continuous stream of saline is maintained. This is done by using two separate vessels, one of them containing the ether and saline solution, the other a 4.1 per cent, physiologic salt solution. The rubber tubes from these vessels are joined to the limbs of a Y-piece of glass tubing, the vertical limb of the glass is connected by means of a rubber tube with the cannula and fitted with an easily regulated stop-cock. This stop-cock makes it possible to inject very small quantities of fluid with absolute uniformity. When a quantity of ether-saline mixture sufficient to establish a satisfactory anesthesia is administered, the ether mixture ANESTHESIA BY COLONIC ABSORPTION OF ETHER 1G7 is shut off with a clamp and physiologic salt solution is slowly injected until the reappearance of reflexes again calls for the addition of the ether mixture, which is accomplished by reversing the clamp to the tube leading from the saline. The glass containers are calibrated so that accurate readings can always be made of the relative quantities of ether and saline solutions. Anesthesia by Colonic Absorption of Ether. — Two methods have been used, the older method of colonic insufflation of ether vapor, the more recent, the method of introducing either mixed in olive oil, the so-called oil-ether method. The advantages formerly urged for anesthesia by colonic absorption in head, neck, and mouth operations have been obtained in the safer and more accurate methods of intra- tracheal and intrapharyngeal anesthesia. In the hands of such men as Sutton, who has perfected ether vapor colonic anesthesia and reported the best results, the method is a fairly safe one; but it is not a safe method in unskilled hands, and it is far more difficult to deal with overdosage inasmuch as the excess of ether vapor in the colon cannot be rapidly eliminated. The same objection is rightfully made against the oil-ether colonic anesthesia. Gwathmy reports over 500 oil-ether anesthesias and favors the method. His conclusions are as follows: 1 . One of the greatest advantages of the method is that the anesthetic can be administered to the patients in bed, without their knowledge, thus fulfilling many principles of anoci association as enunciated by Crile. 2. In over 95 per cent, of cases there has been no eructation of gas during anesthesia. 3. When the patient has been in fair condition there has been not a single instance of colitis, bloody stools, or blood-streaked returns. 4. The oil-ether narcosis is evenly maintained automatically. 5. Postoperative vomiting, nausea, and gas pains are reduced to a negligible quantity. 6. The patient recovers consciousness in the analgesic state. Gwathmy's technic is as follows : Thorough castor oil catharsis the night before operation, followed in the morning by enema. Preliminary medication of chlorotone gr. x, or paraldehyde, 2 oz., in ^ oz. of olive oil by rectum an hour before operation. Half an hour before operation morphine, gr. f, is given hypodermically. Ten minutes before operation the oil-ether enema is started w T ith patient in the Sim's position in his own bed. A 60 to 75 per cent, solution of ether in olive oil is given slowly, using an ounce to every twenty pounds of body weight. Eight ounces of the 75 per cent, mixture will cause the anesthesia to last two to three hours. No more than eight ounces should ever be given. In ten to twenty minutes the patient is in full surgical anesthesia. To relieve overdose symptoms the tube in the rectum is opened and the solution is allowed to run out. 168 ANESTHESIA The common criticism of the method is that it is difficult to gauge the correct dose for operation, which may be short or long, and it is more difficult to prevent overdosage. Treatment of Anesthetic Shock. — The anesthetist must constantly bear in mind the symptoms of overdose and of anesthetic shock. These are most apt to appear in the induction stage or in the late stages of a prolonged operation in a patient of low vitality. When the patient stops breathing, or it becomes impossible to feel his pulse, or the color becomes a dusky gray, the anesthetist must act quickly, but calmly, and the operators must stop their work to help if necessary. If stopping the anesthetic or clearing the air passages fails to restore the patient other measures must be used immediately. 1. Press down on the lower sternum or give the chest a vigorous slap. 2. Lower the head. 3. Open the jaw with a wooden wedge; then apply jaw forceps to keep jaw open, and draw out the tongue and replace it rhythmically at the rate of IS to 20 per minute. 4. An assistant should dilate the sphincter ani. 5. If these measures do not suffice, use artificial respiration. The anesthetist grasps the elbows, presses them firmly against the patient's sides, expelling the air or anesthetic vapor from the lungs ; they should be held with pressure against the chest for four or five seconds. The arms are then abducted above the head. This alternate adduction and abduction of the arms should be done at the rate of 15 per minute. Massage at the precordium is of benefit and can be done by an assistant. Local Anesthesia. — Compression of nerve trunks and local appli- cation of cold to produce a rather poorly defined anesthesia had been known for centuries, but not until the invention of the hypodermic syringe in 1853 by Alexander Wood and the introduction of such drugs as cocaine in 1884, novocaine in 1905, was local anesthesia made practical and efficient. Although in recent years new and safer methods of administering general anesthetics have been developed there still remains a large class of surgical cases where general anes- thesia is either contra-indicated or unnecessary, as in marked valvular disease, or in minor surgical operations. Local anesthesia may be used in such cases with entire satisfaction to both patient and surgeon. Based on the method used, local anesthesia may be accomplished by : 1. Surface application. 2. Infiltration. 3. Regional injection of nerves. 4. Spinal injection. 5. Intravenous or intra-arterial injection. These methods and the materials necessary will be taken up separately : 1. Surface Application. — This method is limited to the mucous membranes and cannot be used on the skin. Cocaine in 2 to 10 per INFILTRATION 169 cent, solutions is applied on a cotton swab to the mucous membrane to be anesthetized. In five to ten minutes the area will be painless. 2. Infiltration. — The infiltration method is the most widely used, and is applicable to almost any surgical field. In this method, because of the large amount of fluid necessary to produce an edema of the several layers of tissue, novocaine in \ to 1 per cent, solution, with a few drops of adrenalin chloride to make a 1 to 20,000 solution is the solu- tion of choice. It is far less toxic than cocaine and can be boiled for purposes of sterilization. The syringe used should be a high grade 5 c.c. syringe, with socket attachment for the needles, so that the syringe can be easily released from the needle for refilling purposes. The tip should be of metal and accurately ground to fit the needles. At least two of these syringes with extra needles should be ready for the operation, so that the assistant can have a refilled one to hand the operator as soon as he discards the empty one. The patient is prepared as for any operation, but the method should be carefully explained to him so that he will not be terrified at the idea of being operated on in the conscious state. He should be wheeled into the operating room with eyes covered, when the noise and hurry of the preparation is over. Many surgeons precede the operation by a hypodermic of morphine gr. \ to \. This allays the nervousness and puts the patient in a neutral state of mind. The surgeon must remember that his anesthetized field is a limited one and consequently his operative field, and he must be far more careful in his retraction and dragging on tissues in and near the wound than when the patient is under general anesthesia. He must remember to work more slowly, deliberately and more carefully than when the patient is unconscious. He must remember to encourage the patient from time to time, and to blame himself if the patient complains of pain. When preparations are complete the surgeon uses a small hypodermic syringe to anesthetize the skin around the first needle prick. This first needle prick should be the only one felt by the patient. A welt is made with the hypodermic and through it the larger needle is introduced and the line of incision is made painless by making a series of connecting wheals in the deeper layer of the skin. Careful anestheti- zation of the skin is essential to keep the patient's confidence, for once the skin is incised the deeper tissues are rendered painless more easily. The vessels and nerve trunks are sensitive. Subcutaneous fat in itself is not. The parietal peritoneum, synovial membrane and periosteum are also exquisitely sensitive and should always be carefully anesthetized. After the skin is incised each layer is made edematous by a series of wheals, and incised. By this method, laparotomies, amputations, excisions of tumors, can be accomplished if the proper care is used to establish anesthesia. Improper syringes, and haste and carelessness on the part of the surgeon will usually result in pain to the patient and chagrin to the surgeon. 170 ANESTHESIA 3. The Regional Method. — -The regional method has been elaborated by Braun who has used it very extensively. It is based on the principle of anesthetizing the sensory nerve trunk or trunks supplying the tissues to be incised. This may be done either by bathing the nerves with the anesthetic (perineural) or by injecting the fluid directly into the nerve substance (endoneural). An accurate knowledge of the sensory nerve supply of the different parts of the body surface is essential to the success of this method. For the details of this work see Braun's monograph. To prepare a J per cent, solution of novocaine with 1 to 20,000 adre- nalin dissolve 0.1 gram of novocaine crystals in 25 c.c. of normal salt solution. Add 1 c.c. of 1 to 1000 solution of adrenalin chloride. Boil this solution for two minutes. Serve from a sterile cup. 4. Spinal Anesthesia. — The injection of a small amount of a 2 per cent, solution of cocaine into the subarachnoid space of the lumbar spine results generally in a more or less complete analgesia of the parts below this point, and often for a considerable distance above. This method of producing anesthesia was first suggested to the pro- fession by Corning in 1885, but was not extensively used for surgical purposes until the publication of Bier's report in 1899. Since that time it has been frequently employed for operations of all kinds on the lower extremities, the male and female genital organs, the rectum, in hernias, and in some laparotomies. After a successful injection insensibility to pain is generally complete in from six to ten minutes. The upper limit of the analgesia is usually at some point between the umbilicus and pubes, but it may be as high as the nipples, or even the axilla?. Method of Injection. — The cocaine solution should be prepared by dissolving the cocaine crystals in distilled water and then placing a test-tube containing the solution in boiling water for two minutes. The lumbar region of the patient should be prepared as for any aseptic operation, and the patient placed in Sim's position, with the spine well arched forward, or, as preferred by many, in the sitting posture, with the elbows resting on the thighs. A slender hypodermic needle three and one-half inches in length should be introduced at a point three-quarters of an inch to the outer side of the tip of the fourth lumbar spine, and carried obliquely inward and upward, passing between the lamina; of the fourth and fifth lumbar vertebra; until the subarachnoid space is reached. This is evidenced by the appearance of a few drops of clear cerebrospinal fluid at the external orifice of the needle. After the escape of five or six drops the syringe, filled with the cocaine solution, is screwed to the needle, and from 8 to 15 minims of a 2 per cent, solution injected. The needle is then withdrawn and the minute cutaneous wound sealed with sterile zinc oxide plaster or collodion. In highly nervous individuals it is often desirable, in order to distract their attention, to go through the form of administering a general anesthetic by using a cone moistened with alcohol or ether. LOCAL VENOUS ANESTHESIA 171 It should be remembered that an appreciation of contact remains in these cases — the patient may feel the pressure of the knife, but he experiences no painful sensation. Spinal cocainization is frequently followed by severe headache, vomiting, and fever, which persist often for from six to thirty-six hours. Sometimes these symptoms are promptly relieved by the hypodermic injection of ^ grain of glonoin, yts grain of hyoscine hydrobromate, or, as suggested by Kuster, by lumbar puncture and the withdrawal of about 10 c.c. of fluid. It is unsafe to make the injection above the second lumbar vertebra on account of the danger of wounding the cord or producing hemorrhage. With a view to avoiding the unpleasant after-effects of cocaine spinal anesthesia, many surgeons have experimented with some of the newer local anesthetics. Oehler has recently reported a series of 1000 cases, and large numbers of observations have been made by Kuster, Holzbach, and others. The concensus of opinion seems to be that tropococaine and novocaine have advantages over cocaine in that they are less toxic, and therefore less likely to be followed by headache and severe vomiting. Eucaine and stovaine seem to be less reliable when employed in this manner. Bier and others have advocated the addition of a small amount of adrenalin to the solution, which delays absorption, prolongs the anesthesia and diminishes the unpleasant sequelae. In the technic of administration it has been suggested that it is well to withdraw an amount of cerebrospinal fluid equal to the amount of solution ejected. Huntington, of San Francisco, who has had an extended experience with tropococaine, dissolves 1 grain of the drug in the fluid removed from the spine and immediately reinjects it. Temporary and complete paralyses have been reported following spinal anesthesia, and a sufficient number of deaths have followed its employment to demonstrate that the method in perfectly healthy individuals is more dangerous than the employment of general anesthesia. Spinal anesthesia is to be recommended only in cases in which positive contra-indications exist to the use of the other anesthetics, and occasionally in emergencies in which a skilled assistant is not available or when other anesthetics cannot be obtained. 5. Local Venous Anesthesia. — For producing anesthesia in operations on the extremities Bier, in 1908, described his method of anesthesia of an entire extremity by injecting novocaine into the superficial veins. The technic is as follows: The extremity is elevated and tightly bandaged with an Esmarch bandage to a point below the site of the vein selected for the introduction of the anesthesia. At a distance of 10 to 25 cm. above this bandage a second is applied. Into the segment of veins between these Esmarch bandages 40 to 50 c.c. of a 0.5 per cent, solution of novocain, without adrenalin, is injected, either directly through the skin and vessel wall, or through the wall 172 ANESTHESIA of an exposed vein. Seventy to eighty c.e. may be injected into the internal saphenous vein for operations on the leg. The tissues in immediate proximity to the injected veins are anesthetized immediately and directly; the tissues of the remainder of the limb distal to the upper bandage are anesthetized in 8 to 10 minutes, indirectly, by the solution bathing the nerve trunks supplied by vessels communicating with the network of superficial veins containing the novocaine. This method has distinct advantages in operations on the extremities where local infiltration is difficult, too extensive or productive of edematous tissues. It is contra-indicated in gangrene of the senile or diabetic type. ANOCI ASSOCIATION. This term has been applied by Crile, of Cleveland, to the technic of combined local and general anesthesia designed to minimize to the least possible degree the shock in surgical procedures. This technic, which is elaborate, requires the most painstaking effort and patience on the part of the surgical staff from the time the patient enters the hospital to his discharge; but the results as obtained by Crile and his assistants more than justify the extraordinary measures used in this surgical treatment. Based on the theory that surgical shock is the result of centripetal nocuous nerve impulses, every step in the technic of anoci association is designed to prevent the incep- tion of injurious nerve impulses or, where they are unavoidable, to prevent such impulses from reaching the sensorium of the patient. Every effort is made to avoid extensive operation in the presence of predisposing causes of shock such 'as hemorrhage, cachexia, acidosis, fear. An attempt is made to remove these predisposing causes whenever possible. Where nocuous impulses are avoidable, such as pain, this is prevented first by anesthetizing the tissues to be incised by local novocaine and urea-quinine infiltration; secondly, by the relatively non-toxic general anesthesia of nitrous oxide-oxygen. The technic as carried out by Crile is as follows: The patient is given a hypodermic of morphine gr. \, scopolomine gr. tytt, an hour before operation. In the operating room, or if neces- sary because of dread of operation, in the patient's room, nitrous oxide-oxygen anesthesia is given. The line of incision and tissue immediately adjacent to the incision are infiltrated with \ per cent, solution of novocaine, followed by \ per cent, of quinine and urea hydrochloride into the tissues, 2-3 cm- away from the planes of incision. Every effort is made to minimize trauma and to incise only such tissues as have been anesthetized. In exophthalmic goitre cases, where fear is such a predisposing cause to shock, a special effort is made to keep the patient quiet mentally and physically, and a special technic is used by which the patient is given preliminary treatments of small amounts of nitrous oxide and ANOCI ASSOCIATION 173 oxygen for several mornings, a bandage is kept on the neck and every effort is made to have the patient regain consciousness, after the operation, in the same surroundings and in the same mental state as on previous mornings. Morphine is used freely in these cases to dull the sensorium, and place the patient in a neutral mental state. It must be thoroughly understood, however, that to use the technic of anoci association successfully, a thoroughly trained staff of surgeons and nurses, willing and anxious to co-operate in minimizing nocuous nerve impulses, not. only in the operating room but in the entire hospital from the time the patient enters until he leaves, is absolutely essential. CHAPTER IX. TREATMENT OF POSTOPERATIVE CONDITIONS. SHOCK. For the etiology, diagnosis, and prognosis of shock the reader is referred to Chapter VI. Here we will consider only the postoperative treatment. Active Treatment of Shock. — The indication to be met is the exhaus- tion of the brain centres and cortical cells, and this is accomplished by two means — rest and renewed blood supply. Cerebral anemia, due to splanchnic dilatation, although not the cause, is a condition constantly present. To overcome this cerebral anemia the following measures should be taken: 1. Lower head of the bed. 2. Apply external heat to extremities. 3. Bandage the extremities. 4. Apply pressure to the abdomen when possible by means of a tight abdominal binder. To constrict the splanchnic vessels, give a hot colon irrigation. If these measures prove unavailing, give an intravenous infusion of normal salt solution, 300-500 c.c, T. 105°, to which is added adrenalin 1 to 1000, Tflxv-xxx. The adrenalin should be thoroughly mixed in the salt solution before the solution passes into the vein. This is very important, as sudden death has occurred by injecting the adrenalin into the vein or into the conducting tube near the vein. If a donor is available, whose blood has been tested previously to determine the question of hemolysis and agglutination, blood trans- fusion is the ideal means of overcoming the shock, for by this means, both the fluid and the nutriment to the exhausted cells is supplied at the same time. Adrenalin is the only drug that can be logically used in shock. It causes a definite constriction of the dilated splanchnic vessels and over- comes the cerebral anemia by giving the heart blood to pump into the depleted areas. Stimulants to the exhausted vital centres are not only of no definite value but actually are harmful, in that they stimu- late exhausted cells. Far better supply blood, carrying nutriment to the brain centres, and rather than overstimulate them with strychnine, put them at rest by means of a small dose of morphine so that the exhaustion can be overcome. This is especially true if the afferent impulses causing the exhaustion of the cortical cells are still passing HEMORRHAGE 175 up to them. This is often the case in recently injured patients, as a result of severe burns or crushing accidents, or in patients suffering from a spreading peritonitis following rupture of a viscus as in gun- shot wounds of the abdomen. In treatment of postoperative complications, one of the most com- mon but important differential diagnoses that has to be made before treatment can be started is the differential diagnosis of shock and hemorrhage. This is given in the chapter on Shock. HEMORRHAGE. Postoperative hemorrhage is usually divided into: (1) primary; (2) delayed; (3) secondary. Primary. — Prophylaxis. — Careful hemostasis should be maintained during the operation. Active Treatment. — Find bleeding point, or if necessary pack with gauze when the vessel cannot be ligated. Delayed. — Prophylaxis. — Be sure that all bloodvessels are ligated. On large vessels use chromic ligatures. Be sure to tie collateral branches that may have been cut. Active Treatment. — Active treatment of hemorrhage may be divided into symptomatic or expectant, and operative; the resort to the latter is determined by the severity of symptoms indicating the degree of hemor- rhage and the failure of expectant measures to control the symptoms. Expectant. — Try to determine site of bleeding. Examine the dress- ing, and observe especially whether there is evidence of fresh bright blood, and if the blood stain, if present, is spreading. A mere staining with pink colored fluid is often present with an oozing exudate, or salt solution left in the peritoneum. If bleeding is found, and can be controlled by a tourniquet, apply it until bleeding vessels can be ligated, or if in a superficial wound, pack with gauze as aseptically as possible. If the case is a celiotomy, examine dressings and drains. If still in doubt, look for dulness in flanks and shifting dulness. Vaginal examination or rectal may disclose fluid in pelvis. If hemorrhage cannot be found and patient is not growing pro- gressively worse, or while preparing for operation: Lower head of bed; give morphine gr. | hypodermically ; apply exter- nal heat; give patient plenty of air. Quiet is essential. If the symp- toms of internal concealed hemorrhage continue and fail to respond to above treatment, an exploratory operation is indicated. The anesthetic should not be started before everything is ready for begin- ning the operation. Ether by the drop method is far preferable to chloroform. Nitrous oxide probably raises the blood-pressure too much. The bleeding point should be found as quickly as possible, tied or clamped, the clamps being left in the wound if necessary; or if the bleeding point cannot be caught, the bleeding area should be packed with gauze. In packing gauze in the abdomen, protect the intestines 176 TREATMENT OF POSTOPERATIVE CONDITIONS from the gauze as far as possible with rubber dam, or by coating the gauze from the packed bleeding area up to the skin surface with albolene or vaselin. This is to prevent the extensive adhesions which form when gauze comes in contact with the peritoneum. As little delay as possible should be incurred in returning the patient to the ward. If possible, blood transfusion should be done in the operating room after the bleeding has been controlled. Transfusion is being used more and more in modern hospitals, and by means of the methods already described any hospital staff can carry out the pro- cedure if a donor can be found. In emergencies a near relative can act as donor even without the preliminary tests for hemolysis and agglutination. (According to recent investigations of the Bacteriologi- cal Department of Columbia University the chances of hemotysis and agglutination are exceeding small if a blood relative is used as donor.) After the hemorrhage has been controlled and if transfusion is not feasible the treatment is the same as for shock. But here replenishing the depleted tissues with fluid is of even greater importance. Hypo- dermoclysis is the method of choice. It can be used in cases where hemostasis is not assured, and where the blood volume can be gradually increased without raising the blood-pressure. POSTOPERATIVE PNEUMONIA. Prophylaxis. — Prophylaxis, as far as the surgeon is concerned, is by far the most important part of the subject of the treatment of post- operative pneumonia. 1. Avoid ether anesthesia in patients having pulmonary disease — especially acute bronchitis and tuberculosis; in old patients; in acute or chronic alcoholic patients. It is exceedingly important to use pure ether. It should be of the best standard grade, guaranteed free from aldehyds and water. It should not be used after standing for any length of time in an opened tin. Wire masks or face pieces of anesthesia apparatuses should be sterilized before using them. 2. In operations on the mouth, nasopharynx and larynx prevent as far as possible the ingress of blood or septic material from the naso- pharynx into the trachea. This is best accomplished by intra- tracheal insufflation anesthesia, or, where this is impossible, by packing the anterior pharynx and giving intrapharyngeal anesthesia through tubes introduced through the nose into the pharynx. 3. Avoid vomiting in the induction of and during the anesthesia. If the patient vomits, keep the head turned to one side and prevent the aspiration of vomitus. This should be particularly emphasized when the patient has left the operating table and is coining out of the anesthesia on the way to the ward, or while in the bed in the ward. Until he has recovered his laryngeal reflex, the patient should be watched by a nurse assigned to that duty. RENAL COMPLICATIONS 177 4. Avoid unnecessary exposure of the patient in the operating room, on the way to the ward, and in the ward while recovering from the anesthesia. The patient should be wrapped in blankets prior to removal to the ward and should be placed in a warm "ether bed" — one previously warmed and kept warm with hot-water bottles. Hot- water bottles should never be placed next to the patient's skin. A towel or blanket should be wrapped around the bottle. Severe burns result when this rule is disregarded. 5. Old or feeble patients should not be allowed to lie on their backs for more than a few hours at a time. They should be frequently turned and made to assume semi-recumbent positions with back-rests. This avoids the so-called hypostatic form of pneumonia. Active Measures. — These depend on the type of pneumonia present. In the capillary pneumonia where there is a marked bronchitis present, the patient should be kept in a warm moist atmosphere, if necessary in a croup tent. In bronchopneumonia type the patient is more comfortable and is more easily cared for in the ward near an open window. In cases where there is frank consolidation, with signs and symptoms of lobar pneumonia, and cyanosis due to toxemia, and with labored breathing, out-door treatment is indicated. The treatment of such cases is the same as in medical cases, largely symptomatic. It is seldom that the treatment, as far as poulticing, cupping and drugs are concerned, cannot be followed as in medical cases. RENAL COMPLICATIONS. These can be grouped under two heads: Those giving symptoms of kidney insufficiency, usually the result of a pre-existing nephritis; and those which develop with or without operation as a result of pyogenic infection of the kidney or kidneys, secondary to a pyogenic infection elsewhere in the body. Predisposing factors to both of these groups of kidney complications are the diminished fluid intake, purging and profuse sweating present during the few hours preceding and following operation, also the loss of fluid associated with hemorrhage and temperature, and by the irritating action of the common anes- thetics — ether and particularly chloroform. The prophylaxis is based on the elimination of these factors. In all cases before operation, fluids, especially water, should be given in generous quantities. If there is any evidence of a nephritis before operation, or if the patient is septic, prophylaxis should be directed along these lines : 1 . As in all ante-operative cases, here especially should water be given and one or two colon irrigations of tap water, three gallons, T. 115°, before operation. If during or after operation there has been bleeding, give colon irrigations t. i. d. three gallons, T. 115°, or a hypodermoclysis of normal saline, 500 to 800 c.c, T. 105°, b. i. d. Avoid exposure of the 12 178 TREATMENT OF POSTOPERATIVE CONDITIONS patient to dampness and cold, especially while recovering from the anesthesia. 2. Never use chloroform, and if nitrous oxide-oxygen is available as an anesthetic and can be given competently, do not use ether. 3. Watch the amount of urine, and make daily urinalyses. Active Treatment. — If suppression threatens, give hot colon irriga- tions every six hours. Apply counter-irritation to both lumbar regions by use of mustard paste or cupping. Give tincture of digitalis, 1T|x, t. i. d. If anuria is present, besides the above measures, use hot packs every twelve hours. Rely on the diaphoresis, colon irrigations and cupping. To prevent pyogenic infection of the kidneys in presence of sepsis elsewhere, keep up the water intake, give urotropine gr. xv, t. i. d. Be very careful to prevent a cystitis if catheterization is necessary. If a suppurative nephritis develops operation may be indicated. TREATMENT OF DISCOMFORT FOLLOWING OPERATION. Under the term discomfort may be grouped several symptoms which are present in varying degree in every patient that has undergone a severe surgical operation. Usually present only for the first twenty- four hours and in a bearable degree, in some patients one or several of these symptoms may amount to a serious condition, and must be classed as a definite postoperative complication. These symptoms are : 1. Pain: (a) Due to the operative wound or operative manipulations. (b) Headache. (c) Backache. (d) Gas pains or abdominal distention. 2. Restlessness and sleeplessness. 3. Nausea and vomiting. 4. Thirst. The treatment of these will be considered separately, but it is necessary at this point to warn against the abuse of the drug that gives the greatest relief during the first few days after operation, i. e., morphine. Too frequently does the busy interne or surgeon fail to get at the cause of the patient's discomfort, and in his haste or desire to keep his patient quiet orders morphine, hypodermically, to be repeated at the discretion of the nurse, and believes that he has done his duty. Instead in many cases he has done actual harm, and, by repeating his mistake, insidiously establishes a craving for morphine that often means a wrecked life for the patient after leaving the hospital. The careless and repeated prescribing of morphine after operation cannot be too strongly condemned. After operation the patient should be brought immediately to his room, or to a recovery room where he is placed in an "ether bed." As soon as possible the TREATMENT OF DISCOMFORT FOLLOWING OPERATION 179 room should be darkened, made quiet and only the nurse or a near relative should remain in the room. The patient's eyes should be covered with a damp compress, and if he is regaining consciousness and is beginning to be noisy or excited, a quiet reassurance on the part of the nurse or parent that the operation is successfully completed, and advice to remain quiet and go to sleep will in the majority of cases of ether anesthesia have a soothing effect on the patient. Stupid with the ether he falls asleep, and in a variable time begins to stir with pain. Now is the time for the hypodermic of morphine, for if it is given after an hour or two following operation the reflexes are active, especially the laryngeal, and if patient vomits he does not aspirate septic material. The morphine at this time usually saves a useless previous dose *of it. The amount, even in peritonitis cases, should be large enough to insure rest and quiet and sleep for several hours; gr. f is the usual adult dose. The severe wound pain can be minimized by care during the opera- tion in the retraction and manipulations of the surgeons. It is not yet well established that quinine urea hydrochloride injected into the tissues, on either side of the planes of incision, prevents pain for several days, but in the hands of some surgeons it apparently prevented much of the postoperative pain. The headache of the first twenty-four hours is almost always due to the anesthetic and an empty stomach. It certainly is more marked after ether than after nitrous oxide-oxygen anesthesia. It is frequently relieved by placing ice compresses on the forehead with an ice cap placed against the top of the head. Sometimes menthol gives great relief when rubbed on the forehead. Backache is almost always the result of the patients' being in the unconscious extremely relaxed condition, lying one to two hours on a metal or glass-top operating table. This relaxation of the trunk muscles throws the strain on the intervertebral ligaments. The strain on these ligaments is accentuated by the customary method of raising a patient by the small of the back from the operating table for the adjustment of abdominal or hernial binders. The best treat- ment is prophylactic. Do not operate on a patient unless he is provided with an air or elastic cushion that fits the lumbar curve of the vertebral column. Insist on the orderlies or assistants lifting the patient in such a way as to keep the body horizontal. For the treatment, after backache has become a marked symptom, the best and most gratifying measure is to make a large, very thick hot flaxseed poultice. Let the patient lie on this so that the poultice fits the entire lumbar region on both sides. It can be renewed if necessary. The so-called gas pains usually appear at the latter part of the first twenty-four hours, and are in reality a form of postoperative distention. For the pain of this distention atropine gr. y^j hypodermic-ally is often valuable. Where morphine is contra-indicated, trivalen is very effectual and has the same analgesic effect. (See treatment of Ileus.) 180 TREATMENT OF POSTOPERATIVE CONDITIONS Restlessness and Sleeplessness. — The restlessness and sleeplessness are always present, but much more marked in some and for a greater length of time than in others. The nervous temperament and nervous condition of the individual has as much to do with these symptoms as does pain. After the first night with use of morphine or of trivalen if necessary, the patient should be given sodium bromide gr. xxx by rectum t. i. d., and everything should be done to relieve apprehension, nervousness and worry. If this is not successful rather than give morphine, which has probably been demanded, give paraldehyd \ oz. to 1 oz. in 2 oz. of water by rectum. Thirst. — Predisposing causes are limited fluid intake just before and after operation, purging, loss of blood before and after opera- tion, profuse sweating of the recovery from ether anesthesia, high temperature associated with the patient's disease, prolonged pyloric obstruction, depletion from any cause; ether anesthesia is probably the most potent predisposing cause. Prophylaxis: Eliminate as far as possible the predisposing causes. Urge the patient to drink plenty of water to within two hours of operation, if necessary give colon irrigations or hypodermoclyses. If much fluid has been lost, if the ether anesthesia was prolonged or if the patient has a temperature, give the patient a hypodermoclysis while still under the influence of the ether. Following operation, with the mouth and tongue furred and dry, unless especially contra-indicated, give water as soon after operation as it is requested. Cracked ice should be avoided as it intensifies the thirst. If the patient has been accustomed to alcoholic drinks and is complaining bitterly of thirst, a high ball of whisky and soda will be pronounced the best drink the patient ever had. Weak tea is at times very much appreciated. Nausea and Vomiting. — Predisposing factors are: Improper prepara- tion of bowel and stomach for operation, by failure to take catharsis or by eating too near the time for operation; manipulation of abdominal viscera, especially upper intestinal tract; pyloric or intestinal obstruc- tion. The most common predisposing cause in the majority of cases is the ether anesthesia. Prophylaxis consists in minimizing or preventing the predisposing causes. For the continued nausea and vomiting that occurs after the first twelve hours and that does not disappear after the usual vomiting following anesthesia, examine the patient carefully for signs of obstruction and dilatation of the stomach. Often even without obstruction a thorough lavage with water at temperature of 120° F. will cause tonic contraction of the wall of stomach with cessa- tion of symptoms. Lavage is the most reliable method of dealing with continued vomiting. Dilute hydrochloric acid or dilute iodine solution ITU to oz. | of water, given by mouth, sometimes relieves the nausea. When the nausea persists for two or three days without signs of obstruction an abrupt change from liquid diet to a light selected solid diet will often immediately relieve this distressing symptom. TREATMENT OF ABDOMINAL DISTENTION 181 TREATMENT OF ABDOMINAL DISTENTION. The treatment of so-called " gas pains" has been mentioned in general in considering the treatment of the discomfort of the patient follow- ing surgical operation. Gas pains probably represent the beginning peristaltic movement of the intestines following the temporary cessa- tion (functionally at least) , due to the exposure and trauma necessitated by abdominal section. Unpleasant as they are to the patient, to the surgeon they are not of unfavorable significance because their presence usually means a re-establishment of the normal motor activity of the intestinal tract which is causing pain because of accumulated gas throughout the tract. ' The subject of abdominal distention will be considered in detail because of its relative frequency and the seriousness of the outcome if not recognized early and properly treated. Under this head can be considered the treatment of three types: (1) Mild abdominal disten- tion, (2) severe abdominal distention, (3) the abdominal distention of ileus (a) functional, (b) mechanical. Following abdominal operations, undoubtedly there is always an accumulation of gas in the gastrointestinal tract which varies in amount over the normal, within wide limits; and also, as mentioned before, there is probably an almost complete cessation of intestinal muscular activity for some hours following operation. When for some reason the intestinal wall does not regain its tonicity, or having regained it, fails to maintain sufficient peristaltic force to adequately expel the accumulated gas, the resulting symptom-complex is known as abdominal distention. The term ileus signifies a symptom-complex resulting from the arrest of passage of intestinal contents. In general, prophylaxis is the key- note of the treatment of abdominal distention, and this can be divided into: (a) Ante-operative treatment, (6) treatment during operation, (c) postoperative treatment. (a) Ante-operative Prophylactic Treatment. — A thorough cleaning out of the gastro-intestinal tract is essential before operation, and the cases (as for instance, the emergency cases), in which there has not been sufficient time to do this, are most prone to postoperative distention. On the other hand, too severe purging before operation is to be dis- couraged, as it may defeat its purpose and produce just what it aims to avoid. In a routine case upon which an abdominal operation is to be performed in the morning, for instance, no extensive preparation is necessary. The preparation should be as simple as possible. On the day previous, the patient may enjoy a light evening meal, and that night castor oil § j-5 iss, or some equally efficacious cathartic, should be given, followed by a requisite number of soapsuds enemata, six hours before operation, to be given until the return is clear. Usually 182 TREATMENT OF POSTOPERATIVE CONDITIONS two will suffice. Water by mouth should be encouraged up to two hours before operation. (b) Prophylactic Treatment During Operation. — Abdominal distention is distinctly less frequent and severe in cases in which gas and oxygen are used throughout as the general anesthetic and infiltration with local anesthesia is used at the site of operation. The most important prophylactic measures, however, and these cannot be too strongly emphasized, are gentleness on the part of the surgeon in manipulation of the intestines, great care in the actual handling of viscera and in placing retractors, and a minimum amount of exposure. It can be truly said that postoperative distention varies in direct proportion to the amount of trauma to which the viscera are subjected at the time of operation. In dealing with infective conditions a minimum amount of trauma is even more important, because of the direct effect of infection within the peritoneal cavity upon distention. (c) Postoperative Prophylaxis. — Because of the possibility of disten- tion and also because of the usual depletion of the patient following an abdominal operation, and the consequent need of fluids, an excellent method of prophylaxis to be employed is the early use of colon irriga- tions as a routine measure. They may be begun eight hours after operation and can be repeated every eight hours, or twice a day, and can be alternated with salt solution per rectum to be retained about 4 to 6 oz. every eight hours. These will alleviate thirst, will be found to be stimulating and if properly given will cause practically no dis- comfort. As do all postoperative measures, however, they require care in the giving, and only too often is the entire procedure left to an untrained attendant. A method which has proven efficient over a large series of cases and which causes the patient, under ordinary conditions, no discomfort whatever, is as follows: (1) Ordinary tap water is used at a maintained temperature of 120° F., (2) the rubber tubing should consist of: (a) an outlet tube — one large rectal tube with a distal opening and at least three large lateral fenestra? (this should not be too soft but very flexible), (b) an inlet tube — an ordinary medium-sized catheter, (c) sufficient ordinary rubber tubing to connect the inlet tube with the irrigating can and the outlet tube with a pail. Glass connecting rods can be used to connect the various segments of tubing. The irrigating can is brought to the side of the bed at about 8"-12" above the bed level; the water is made ready and both very hot and cold water should be at hand to regulate the temperature of the irrigat- ing fluid, as indicated by a thermometer. The water from the irrigat- ing can is allowed to flow through the tubing until it is well heated and the air is expelled by the column of water which completely fills it. Then with the tip of the inlet tube introduced into the distal lateral fenestra of the outlet tube, and both well lubricated, they are introduced as one into the rectum, the patient being asked to "bear TREATMENT OF ABDOMINAL DISTENTION 183 down as if straining at stool," while the tubes are passed by the sphincter. If hemorrhoids are present or rectal tenesmus exists, a simple method of completely lubricating the rectal canal is to introduce vaselin into the rectum by means of a fenestrated hard-rubber nozzle, into which the lubricating medium is gently forced by a screw cap outside. This will make the introduction of the tubes practically painless. The outlet tube is introduced for a greater distance than the inlet, approximately 6 to 9 inches for the outlet tube, and 3 to 4 inches for the inlet tube, and the water is allowed to run, the return flow passing down into a good-sized receptacle on the floor. A colon irrigation must be watched all the time by the person in charge. If the outflow ceases during the operation, gentle manipulation of the outlet tube will usually cause it to begin again at once; if not, the inlet tube is pinched, shutting off the inflow until by manipulation of the tubes the outflow is resumed. From 3 to 5 gallons of water is used and it is allowed to flow in slowly, the entire process taking from forty-five minutes to an hour. During the procedure the patient remains in a dorsal position with the thighs and legs comfortably flexed, and if properly given the hot irrigating fluid readily passes around to the ileocecal junction, thus reaching the entire absorbing surface of the colon. A colon irrigation is considered effective, if besides the intake of water which the patient absorbs, which varies from a pint to two pints, fecal material and flatus are expelled, the amount of the latter being estimated by observing the bubbles of gas escaping from the end of the outlet tube, which ought to be submerged in the water in the receptacle for the outflow. 1 . Active Treatment of Mild Abdominal Distention. — Usually moderate distention as evidenced clinically by the physical signs of accumulation of gas in the gastro-intestinal tract and some abdominal discomfort on the part of the patient on the first and second day following opera- tion, is but temporary and responds readily to treatment. This is not alarming. In these cases frequently, simply the introduction of a rectal tube is sufficient to start the expulsion of flatus, and no more difficulty ensues. Placing the patient on his side with thighs flexed frequently assists also in the expulsion of gas. These failing, a soap- suds enema can be given with good results, or the routine colon irriga- tions, usually on the second day, stimulate peristalsis and gas is expelled. Later on during convalescence mild distention usually can be controlled by the above methods in addition to regulation of diet (especially the elimination of milk), and catharsis. 2. Treatment of Severe Abdominal Distention. — We now come to the consideration of cases in which distention is present and apparently increasing, and the patient is passing but a small amount of flatus 184 TREATMENT OF POSTOPERATIVE CONDITIONS per rectum on the third or fourth day. One has here an entirely different problem with which to deal. It is now most important to get results and quickly. The danger is a very real one. The distention may increase, embarrassing the respiration and even the heart action; tendency to kinking of the distended intestines is increased and, finally, it may terminate fatally. One should be able to determine whether the distension is involving chiefly the small intestine, large intestine or stomach by the physical signs, especially percussion; but not always is this possible. If there is any suspicion of gastric distention, a lavage with very hot tap water (temperature 115° to 120° F.) should be given at once and this gives the patient the benefit of the doubt. If a large amount of flatus and gastric contents are found, lavage can be continued until practically no more gas escapes and the return is clear. Too frequently this postoperative complication is not recognized and treated in this simple way until the patient is hiccoughing or even vomiting, or until it is too late. Lavage may be repeated as indicated every four hours and very hot water is strongly recommended for its stimulating effect both upon the gastric wall and generally. Sometimes the addition of sodium bicarbonate is of advantage in the water and at times magnesium sulphate Bss-gj may be introduced through the tube and allowed to remain after lavage in general abdominal distention, in a further effort to stimulate peristalsis. Medical enemata in combination with hot turpentine stupes are most useful, to be employed in addition to the colon irrigations and lavage. Of drugs, of somewhat doubtful value, eserin gr. ■£$ or pituitary extract 1 c.c, given hypodermically, may prove of value, and when they do, are very efficacious. The most efficient enemata for this purpose are those containing turpentine, ox-gall, assafetida, glycerin or milk and molasses. They may be used as follows: Turpentine, g ij Olive oil, 5 viij followed in one hour by a soapsuds enema; or, Fel bo vis, gss Salt solution, Oj followed in one hour by a soapsuds enema; or, Fel bovis, gj Turpentine, gij Soapsuds, Oj or, Assafetida, giij Soapsuds, q. s. ad Oj Any one of the above enemata can be given together with the stuping. As in giving colon irrigations, so in applying turpentine stupes, the result depends to a very large degree upon the manner in which they are administered. TREATMENT OF ABDOMINAL DISTENTION 185 Turpentine stupes to be efficient should be administered as follows: Flannel squares are used and these are large enough to extend over the entire abdomen and chest wall from the mammary line to the pubis and well down on the flanks. There should be at least six thicknesses of flannel. The abdominal binder and cotton if present are removed, leaving only a single dressing over the wound. All of the exposed skin of the abdomen and chest should be well greased with vaselin to prevent burning of the skin by the hot stupes. The stupes are made by first soaking and then wringing t>ut by means of wringing rods the squares of flannel in very hot water to which turpentine about § iv to the quart has been added. This should be done at the bedside and the stupes applied immediately, changed every ten minutes and applied for one-half hour every two hours until results are obtained. 3. Abdominal Distention due to Paralytic Ileus. — This represents the very grave type in which there is an arrest of the passage of intestinal contents, following operation. It is usually associated with sepsis and especially spreading peritonitis, although it may simply represent a further stage of the severe type of distention. Catharsis, although employed by some surgeons, has not met with success in our hands in this type of case. In the milder types of post- operative distention and before the paralytic stage has been reached it is of real value. In the type under consideration, frequent and repeated washings of the gastro-intestinal tract from above and below, drastic enemata and turpentine stupes are by far the most efficient methods of treat- ment. Eserin and pituitary extract, hypodermically, are also used in repeated dosage and strychnin in large doses is advised by many surgeons. Placing the patient in a semisitting posture may also be of some benefit. The efficacy both of the lavage and colon irrigations is greatly increased by using water as hot as the patient can comfort- ably bear. The indication is to re-establish normal peristaltic movement as evidenced clinically by the spontaneous expulsion of flatus; with this object in view there should be no cessation in the treatment, except for short periods of rest for the patient, until this has been accom- plished. In the meantime, the patient should be given nothing by mouth, some simple wash being used to keep the mouth moist. Not until all vomiting has ceased and flatus has been expelled should the intake of fluids be resumed. The simplest fluid, as albumen water with orange juice § j-§ij every two hours, should be given, and when albumen water and broth have been successfully taken, more of the ordinary fluids and in larger amounts can be easily digested. When depletion of bodily fluids exists, as in septic cases, hypo- dermoclysis can be given. Proctoclysis or the Murphy drip method is frequently very satisfactory and the amount of fluid absorbed some- times is astonishing, as much as a pint an hour being absorbed usually without any difficulty until the normal balance is re-established. This L86 TREATMENT OF POSTOPERATIVE CONDITIONS can be -arranged by using a small irrigating ean, 4 to "> inches above the bed level, the water in which can be kept hot by means of a small electric heater, a short connecting tube uniting the irrigating can with a double-bulbed rectal nozzle (Fig. 85) or good-sized rectal tube with lateral fenestra, which is inserted from 3 to 5 inches into the rectum. The fluid will wash back and forth, thus allowing gas and fecal matter to escape as the fluid is absorbed. This method of proctoclysis is valuable in any of the postoperative conditions in which there is an indication for giving fluids and stimulating peristalsis. Because of the possibility of obstruction, cases of persistent post- operative distention which seem to be getting worse, despite vigorous treatment as indicated over a reasonable length of time, are to be oper- ated upon. This is generally best accomplished by means of a median incision, and in the event of finding no definite obstruction, such as angulation or an adhesive band, a low enterostomy may be of value — A Paul tube is inserted and the intestine, after the escape of gas in the immediate vicinity of the opening, can be irrigated with very hot saline solution or water, and this may later be frequently repeated. Fig. 85. — Electa! nozzle for Murphy drip. Distention Following Mechanical Ileus. — Postoperative intestinal obstruction may occur early, immediately following operation, or late, due to connective-tissue adhesions. It is only the early type which we shall now consider. Frequently the cause is a kinking of the intestines when put back into the peritoneal cavity at operation. In cases of peritonitis especially is this true, as the intestine is already paralyzed; in other cases the kinking takes place in an overdistended intestine, as found in paralytic ileus. Drainage tubes may also cause mechanical obstruction. The diagnosis of this condition is very difficult, and especially is the differential diagnosis between this and paralytic ileus made difficult by the very nature of the cases in which they most frequently occur, and the presence of infection. The symptoms are frequently the same as in paralytic ileus and there is ordinarily no sudden pain. The symptoms may appear from two to ten days after the operation, and they may appear suddenly as acute colicky pains followed by increasing distention, which at first, however, may be localized; failure to pass flatus and vomiting indicating a sudden obstruction with interference of the blood supply. On the other hand when secondary to a pre-existing paralytic ileus, as is frequently the case, THROMBOSIS AXD EMBOLISM Is, the symptoms as mentioned are frequently the same as in the former, and appear gradually, there being no sudden sharp pain but simply an increasing distention, failure to pass gas, vomiting and finally shock. The treatment, therefore, in any ease of postoperative distention should be all the more thoroughly carried out because it may prevent the actual occurrence of later obstruction. If all the palliative means suggested under paralytic ileus have been employed and have failed, operation is indicated to remove the cause of obstruction. When to operate, however, in a given case is indeed a very difficult question to decide, and the difficulty of diagnosis makes it more so. In any form of severe, persistent postoperative distention, certainly delay is more dangerous than operation. If a mechanical cause is suspected and the patient is in fair condition, a median incision can be used, through which a quick and thorough exploration can be made and the cause of the obstruction removed if found, and if not found a low enterostomy can be performed and a Paul tube used, as previously mentioned. If the patient's condition does not warrant this, as a last resort, an enterostomy can be made with local anesthesia. THROMBOSIS AND EMBOLISM. Thrombophlebitis is one of the postoperative complications which, although not occurring frequently, when it does appear causes much discomfort to the patient, is not easily amenable to treatment, and may be associated with embolism. In a recent series of 6S25 cases operated upon at the Mayo Clinic, thrombophlebitis of the internal or external saphenous veins occurred in 14. Infection, as far as the type of the case is concerned, seems to play no part in the occurrence of this complication, as it occurs in the so-called clean cases as frequently as in the infected. It usually occurs in the second or third week after operation, involves the saphenous and femoral veins chiefly, is more common on the left side and most frequently follows operations in the pelvis or lower abdomen and especially in anemic patients. The treatment consists in prophylaxis and active treatment. The prophylaxis consists in the usual care in subjecting the patient to the minimum amount of trauma at operation, especial care being taken to carefully ligate bloodvessels rather than traumatize them directly or by retractors. The active treatment consists, in brief, of absolute rest in bed for from three to six weeks, local application of heat or cold to the part and elevation of the affected limb on a soft pillow where it can be protected. Ichthyol locally by some surgeons is considered of value. Massage of any sort is to be avoided. Pulmonary Embolism. — The time for sitting up, getting out of bed and walking around seems to bear no important relation to this con- 188 TREATMENT OF POSTOPERATIVE CONDITIONS dition. It is one of the most distressing of the surgical accidents which may happen during convalescence and usually happens when least expected. In cases in which blocking of one of the main branches of the pul- monary artery has taken place, practically no opportunity is afforded for treatment. If, however, the patient survives the initial shock, a large dose of morphine should be given immediately, absolute quiet maintained, heat applied to the extremities and cardiac and respira- tory stimulants given as indicated. Atrophine sulphate gr. ^ hypo- dermatically is a good respiratory stimulant, while for cardiac distress strophanthine gr. y^ or digitalin gr. T \^ intravenously and camphor gr. j in oil Mix are among the most valuable. Recovery, however, depends upon the situation and size of the embolus. CHAPTER X. INJURIES AND DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUES. INJURIES OF THE SKIN. Burns and Scalds. — Burns and scalds are injuries due to the effects of heat. Burns are caused by contact with a flame or some hot solid substance, by exposure to the rays of the sun or the a-rays, by contact with a strong electric current, or simply by heat radiated from flame or some hot object. Scalds are produced by contact with steam or some boiling or heated liquid. The nature of the two injuries is identical, although their lesions may differ somewhat in appearance. The effect of the irritation is to produce a reactionary congestion, superficial dermatitis, or more or less extensive necrosis of tissue. Dupuytren's classification of burns into six degrees has been generally adopted: first degree, characterized by simple hyperemia of the skin; second, dermatitis with vesicles or bullae; third, necrosis of the super- ficial layer of the skin; fourth, complete necrosis of the skin; fifth, necrosis of the skin, subcutaneous tissue, and muscle; sixth, complete "carbonization" of an extremity. Symptoms. — The symptoms of burns and scalds depend upon the location and extent of the injury and the character of the burning agent. They may be divided into local and constitutional. The local symptoms of a burn are a sense of heat, smarting, and general discomfort, more or less pain, tenderness, and inability to use the part. In addition there are redness and swelling of the skin, blisters or sloughing. In the severer forms the skin may be blackened and leathery. In scalds the skin is whitened, thrown into ruga?, and often the epidermis is detached (Fig. 8G). The constitutional symptoms of burns are relatively wholly out of proportion to the apparent injury, and are relatively greater in children and in cases in which the trunk is largely involved. Shock is present in nearly all burns, and is dependent more upon the location and extent of the burned area than the depth of the injury. It is generally fatal if an area equal to one-third of the surface of the body is involved, and in cases in which much less of the surface is injured in children, especially if the burn occurs on the chest or abdomen. Elevation of temperature and other symptoms of grave toxemia are present in severe burns accompanied by extensive necrosis. This in the early stage is probably due to absorption of toxic substances from the burned tissues; later, to sepsis. Headache, restlessness, delirium, and coma 190 INJURIES AND DISEASES OF THE SKIN may follow a burn, due to meningeal congestion and exudate, and in certain rare cases a duodenal ulcer will develop, evidenced by local pain, hemorrhage from the stomach or bowels, and in case of perfora- tion by the sudden appearance of severe epigastric pain accompanied by evidences of local peritonitis and progressively increasing shock. A more or less acute nephritis is frequently associated with an extensive burn, and may cause death from suppression of urine or more slowly developing uremic symptoms. When the patient has been exposed to flame, steam, or hot vapors, edema of the glottis may occur, with severe bronchitis and pneumonia. Retention of urine occasionally results from edema of the prepuce or swelling of the glans. Treatment. — The treatment of burns of limited extent and of moder- ate severity consists in rest and the application of a dressing of a saturated solution of sodium bicarbonate, carbolic acid (1 to 100), normal salt solution, or the use of some emollient ointment, as zinc Fig. 86.— Scald of the hand. oxide or boric acid. Where blebs form, their entire dome should be trimmed away with scissors and their contents removed to prevent its becoming infected. Not infrequently patients present themselves for treatment after extensive burns have been dressed with dry gauze, which has become firmly adherent to the entire burnt area. Rather than attempt the immediate removal of the dressing, which would in all probability be attended with some bleeding and great discomfort to the patient, it is better to saturate the adherent gauze dressings with a bland oil such as albolene, then cover it with rubber tissue to prevent evaporation and wait for twenty-four hours, at which time the dressing should be easily and painlessly removed. In the severer forms, especially when the papillary layer of the skin is exposed, the burned surface should be immediately protected from the air and dressed as infrequently as possible. The pain should be controlled by small doses of codeine or morphine, although it must be remembered that in the severest cases, accompanied by grave toxemia, morphine INJURIES OF THE SKIS 101 tends to retard elimination, and should be used sparingly. Fainting the granulating surface of a painful burn with a 2 per cent, solution of silver nitrate will often give marked relief. In severe burns accom- panied by necrosis of tissue, if possible the parts should be disinfected and dressed antiseptically. The plan of treating extensive burns without any dressing has of late been extensively employed. The patient is placed in a bed so arranged that the body is covered by a hood made of a blanket or piece of canvas, the head being outside (Fig. 87). The space beneath the hood is heated to about 100° F. by means of a hot-air generator or electric heater; or the patient simply lies in an ordinary bed without coverings, in a room in which the temperature is raised to 100° F. or above. As a result of this treatment the burnecl area is soon covered by a thick dry crust which Fig. 87. -Dry warm-air treatment of burns. Electric heater under crib with warm-air pipe on each side. excludes the air, gives great comfort, and allows the healing process when aseptic to advance as under any other protective dressing. In extensive burns, where the crust formation is slow, it may be favored by the use of an electric fan, which promotes rapid drying of the moist surfaces. In favorable cases cicatrization takes place beneath the crusts. Where much infection is present, or when the resistance of the individual is reduced, suppuration occurs beneath the scabs, and may give rise to marked systemic reaction. Occasionally this may be reduced by removing a portion of the scab to allow drainage, but generally it is better to remove the crust by a warm bath in a solution of soda bicarbonate at a temperature of 96° and allow another to form, or treat the ulcer by a wet aseptic dressing or some antiseptic- powder. 192 INJURIES AND DISEASES OF THE SKIN Shock should be treated by stimulants and food, meningeal irritation by sedatives and ice to the head, visceral congestion by a cold-water coil. An effort should always be made to promote elimination of the toxins by cathartics and diuretics; and if sepsis follows, supporting measures should be faithfully employed. The healing of large granulating surfaces may be hastened by strapping or skin-grafting. Fig. 88. — Subcutaneous hematoma of the thigh. Contusions. — These are cutaneous and subcutaneous injuries caused by blows or crushes, and are associated with rupture of one or more small vessels in the skin or cellular tissue. The hemorrhage thus produced may be slight, giving rise to a dark bluish discoloration of the skin; or it may be greater in extent, and form a large collection or hematoma (Fig. 88). Contusions often are associated with wounds of the skin and other injuries of the soft parts. DISEASES OF THE SKIN I'.k; Treatment. — The treatment of contusions, when any is necessary, should consist in rest for the part and the application of heat or cold by means of fomentations or wet dressings of aluminum acetate. If uninfected, and not increasing in size, hematomata should not be opened; the fluid, however, may be withdrawn by aspiration. If infection occurs, a free incision should be made, the cavity emptied of clots, thoroughly disinfected, and closed with sutures and drainage, or packed and allowed to heal by granulation. DISEASES OF THE SKIN. Dermatitis. — The various forms of simple dermatitis are described in text-books on Dermatology. Erysipelas is described in Chapter III. '•■ -j*, \< * ( M 1111191 ' i&j&i '-•■ Fig. 89. — X-ray dermatitis of the hands. X-ray Dermatitis. — Exposure to the Rontgen rays produces a variety of skin lesions. A single long exposure may give rise to an area of hyperemia which is tender to the touch, and often the seat of some spontaneous pain, the so-called x-ray burn. More prolonged exposure to the rays or repeated exposures may give rise to chronic hyperemia, dryness of the skin from atrophy of the sweat gland, deformed and brittle nails, keratoses, papillomata, and superficial and deep ulcerations. These lesions are all exceedingly chronic, and any ulcerative process is apt to be associated with severe pain (Fig. 89). Porter and White have recently reported the histories of eleven cases where x-i&y ulcerations have undergone epitheliomatous change. 13 194 IXJURIES AND DISEASES OF THE SKIN All of these occurred in .r-ray operators, and in many cases the disease began before the general use of protective agents. In one case illus- trated in their report, ten different epitheliomatous tumors developed in a period of five years, requiring twenty-five operations under ether. Treatment. — The treatment of the milder cases of x-ray dermatitis consists in soothing applications and the avoidance of all sources of irritation. Vaselin, cold cream, orthoform, and a wet dressing of aluminum acetate will be found useful. For the ulcerative lesions which resist palliative treatment, excision with skin-grafting consti- tutes the best treatment. For ulcerations which show beginning malignant change, without evidence of lymph-node metastasis, radium therapy is of value; in more advanced disease w'de excision or ampu- tation i> to be recommended. Furuncle, or Boil. — Furuncle is a localized inflammation of the skin around a hair follicle or the duct of a sebaceous gland, due to an infec- tion, generally by Staphylococcus pyogenes aureus or albus. The tissues in the immediate neighborhood of the follicle or duct become necrosed and surrounded by an area of congestion and inflammatory exudate. If undisturbed, the necrotic mass gradually softens and forms a small cavity filled with pus, which eventually ruptures through the epidermis, discharges, and heals. Boils are apt to appear in crops and often in apparently healthy individuals, due to infection being carried from one part to another by fingers or articles of clothing. Symptoms. — The symptoms of a bob 1 are first a localized point of tenderness, which is soon followed by a small reddened conical area of induration, on the apex of which a small vesicle is often seen. There is usually considerable pain of a throbbing character, with marked tenderness and muscular rigidity in the region. Furuncles may occur anywhere, but are seen more frequently on the neck, face, buttocks. arms, and in the axilhe. Treatment. — The treatment should be to promote early softening of the necrosed mass and evacuation of the pus. This is accomplished best by a wet dressing of mercuric chloride (1 to 5000) or a flaxseed poultice, with incision as soon as softening is detected. While most modern surgical authorities condemn the use of poultices on the ground that they favor the spread of infection by allowing the pus from a discharging furuncle to infect surrounding healthy follicles, there is no objection to their employment before the focus is opened, at which time they often relieve pain, favor early softening, and con- tribute to the comfort of the patient. The use of Bier's hyperemic cups after a comparatively small incision will hasten resolution in many cases and avoid conspicuous cicatrices. Early incision through the necrosed area, followed by a wet bichloride dressing, will often save time by aborting the process. Removal of the offending hair when present and applying pure carbolic acid to its follicle by means of a pointed match or toothpick is recom- mended in the early stages. To prevent a succession of boils, the sur- DISEASES OF THE SKIN 195 rounding parts should be washed frequently with soap and water, afterward bathed with a solution of bichloride ( 1 to 1000), and protected by a dressing of sterile gauze. The use of autogenous vaccines in cases which have repeated recurrences is often of considerable value. Care should be taken to disinfect the fingers after dressing or handling the infected region. Furuncles in the early stage often may be aborted by the application of an ointment or plaster of salicylic acid. Klotz's formula is the following: Empl. plumbi, 60 Empl. saponis, 25 Petrol;. ti. 8 Cerat. jap., 2 Ac. salicylici, * o — M. Cellulitis. — Cellulitis is an inflammation of the cellular tissue. All tissues are cellular, but what is meant by the term "cellular tissue" in general are those tissues made up of the more non-specialized con- nective-tissue cells that are the framework supporting more highly specialized cells, and the agencies through which they obtain their nutrition. For instance, subcutaneous tissue, fascial planes, and the interstitial substance of organs are examples of cellular tissues. Theo- retically, it is difficult to conceive of a pure cellulitis without involve- ment of other more specialized tissues. Clinically, however, the term is widely used — most frequently in describing inflammatory processes in the subcutaneous tissues or intermuscular fascial planes, as in a deep cellulitis of the neck or Ludwig's angina, in the tissues of the orbit, in the perineal fascial planes, or in the tissues outside the peritoneum, etc. The intensity and extent of a cellulitis varies considerably with the nature of the infecting agent, the susceptibility of the individual and the structure and vascularity of the part affected. In general, strep- tococci, a virulent strain of colon bacilli or staphylococci, or an organ- ism such as the Bacillus aerogenes capsulatus, or even an extravasation of normal urine may cause an exceedingly rapid progressing cellulitis, but the usual type of staphylococcus aureus or albus, which is by far the commonest infective agent, may cause a distinctly localized and gradually spreading cellulitis with termination in abscess for- mation. Cellulitis in a diabetic, in an individual with spinal cord lesion, or in an arteriosclerotic alcoholic, may be rapidly fatal. A cellulitis where the tissues are loose and vascular, such as the back of the hand, scrotum, lip or eyelid, is generally very rapid in its course, but in the palm of the hand or in the tissues of the back it becomes localized more readily. In a general way the causes, symptoms and treatment of cellulitis may be indicated as follows: Causes. — First, trauma — such as friction, heat, frost, counter-irritants, injections of irritating drugs or sera, snake or insect bites, etc. 196 INJURIES AND DISEASES OF THE SKIN Second, infection — through wounds, by extension from already existing infections, by transmission through blood or lymph stream, etc. Third, metabolic disturbances, such as gout. Symptoms. — Tense, throbbing pain, increased by motion; impair- ment or loss of function, tenderness, redness, heat, swelling, tenderness and enlargement of associated lymph nodes, leukocytosis and the general systemic symptoms of fever. Treatment. — Rest, local (splint), rest in bed, sedatives if necessary, copious water drinking, catharsis, moist heat, poultices, wet dressings, etc., intermittently; external medication, ichthyol or mercurial oint- ment, aluminum acetate solutions, etc. ,f££!iigjggg^gN Fiu. 90. — Diagram showing the layers and structure; subcutaneous tissue. )f the skin and Operative Treatment. — The question as to when and how to operate on cellulitis cases is important. It is exceedingly difficult to tell whether a cellulitis is going to break down and form an abscess or not. Where the process is diffuse and there is no definite point of extreme tenderness or sign of fluctuation, and where the patient's general condition is not serious, it is far better to treat conservatively. In most cases after twenty-four or forty-eight hours, the diffused process is either subsiding or a definite area of abscess formation can be made out. During this time it is often useful, besides putting the patient to bed and administering a cathartic, to immobilize the part as much as possible and every two hours apply moist heat directly through the DISEASES OF THE SKIN 197 dressing for half an hour at a time. It is questionable of how much value various types of dressing are; 20 per cent, ichthyol ointment, 10 per cent, blue ointment or aluminum acetate dressings, or even plain salt solution dressings are serviceable. In certain cases of cellulitis the infiltration involves important structures, as in the deep cellulitis Fig. 91. — Diagrammatic drawing of a subcutaneous abscess at an early stage where the dividing line between living and necrotic tissue has not yet been established. of the neck. The patient may be extremely sick and operation may be indicated. In such circumstances the incision must be free enough to allow of the exposure of enough of the affected area to overcome the danger of the absorption incidental to the effect of any operation. Where the process has localized the abscess should be treated as under ordinarv circumstances. Fig. 92. — Diagram of a subcutaneous abscess after incision, where the dividing line between living and necrotic tissue has been established, except where the dense trabeculse of the subcutaneous tissue are still attached to the slough or "core" of the boil. It is through the action of the living cells (e. g., phagocytes) in the granulating wall of the abscess that complete solution of these trabeculse takes place and "sequestra- tion" becomes complete. A, necrotic tissue slough; B, dense subcutaneous tissue trabecules surrounded by living cells; C, granulating wall of abscess. Subcutaneous Abscess (Figs. 91 and 92). — In dealing with a sub- cutaneous abscess, it is important to remember that the corium as well as the epidermis must be penetrated before adequate drainage of the abscess cavity itself can be effected. There is a wide variation in the density and thickness of the corium in different parts of the body. An insufficient 198 INJURIES AND DISEASES OF THE SKIN opening through this layer is a frequent factor in the failure to establish adequate drainage. In many such abscesses sufficient drainage can be established by using pure carbolic acid to enlarge an already existing small sinus. Its action is such as to shrivel up and anesthetize the tissues. By carefully applying with a pointed toothpick the diameter of the sinus can be considerably enlarged. Sometimes a very minute strip of tape or even soft white cotton twine soaked in pure carbolic may be left in the sinus as a drain. Care must be taken to prevent dry crusting of the exudate in the dressing of a recently opened abscess. This is best done by the use of either ointment or wet dressings or by w^w0$$m mm W "' $ MMi: ^»: :& •'..& -c — D Fig. 93.- — Diagrammatic drawing of a carbuncle. ^4, cribriform holes in the epidermis; B, area of induration; C, corium; D, subcutaneous tissue; E, abscess formation aboul the hair follicles and sweat glands; F, central area of necrosis; G, deep extravasation of pus over fascia covering the muscle; H, deep fascia covering muscle. telling the patient to soak the part in hot water. Frequently the application of poultices directly over the dressing affords great comfort and creates an active hyperemia. Carbuncle. — ( arbuncles occur practically always where there is hair. The common sites are the back of the neck, the back of the hand, the face, particularly the upper or lower lip. They are really collections of abscesses that have varying degrees of communication about a central area of necrosis. They are generally superficial to a deep collection of pus that has, as it were, mushroomed out along the deep fascia covering the muscular planes. These abscesses project along the sweat glands and hair follicles, by way of the fat bundles that surround them, DISEASES OF THE SKIN 199 toward the skin. The surface appearance of a carbuncle generally shows a swelling covered by epithelium presenting several small holes exuding pus. About this area is an indurated zone of considerable extent (Fig. 93). Treatment. — The central portion of a carbuncle is not sensitive until the deep fascia is reached. Small and moderate-sized carbuncles can readily be operated upon under novocaine anesthesia. Larger ones require gas and oxygen. A crucial incision should be made completely through the area of induration. The flaps are then dissected free, so that the whole area of induration has been thoroughly undermined. This is best done by incising the skin with a knife and completing the incision with blunt-pointed scissors. In this w T ay care can be taken not to injure the deep fascia or the muscle that may underlie it. Drain- age and dressing are similar to that of an ordinary abscess. The use of a solution of camphor 60, pure carbolic 30, alcohol 10 on the gauze drain after opening an abscess or carbuncle (not its subsequent dressings) can be recommended. By far the commonest place for superficial infections to occur is in the hand and fingers. In the succeeding pages a description of the surgical anatomy and the management of such infections will be given. Hand Infections. — In considering these infections it is well to have an accurate knowledge of the surgical anatomy and to define and describe the terminology that will be used. Eponychium. — This refers to those tissues covering the base of the nail, composed of a superficial layer of epithelium, forming the dorsal epidermis of the finger, which, at its distal free edge, is attached to the nail, and reflected proximally to fuse w T ith the proximal edge of the nail matrix epithelium. These tw T o epithelial layers, the superficial and the reflected, together with a small amount of cellular tissue between them, are the eponychium. Paronychium. — This structure is in continuity with and quite anal- ogous to the structure of the eponychium except that it is situated along the side of the nail, is less intimately attached to the nail distally, and that the reflected edge is continuous with the epithelial layer of the nail bed and not continuous with the nail matrix epithelium as in the eponychium. The subcutaneous tissues, however, of the paronychium and the eponychium are continuous and intimate, not only anatomically but clinically. The Nail. — The nail body is that portion of the nail which ex- tends from the lunula to its free distal edge. The nail base is that portion of the nail corresponding to the lunula and extending proximally into the re-entrant angle of epithelium formed by the junction of the reflected layer of epithelium of the eponychium and the epithelium of the nail matrix. The shape of the nail at this point is tapering or chisel shaped, its thickest portion being at the distal margin of the lunula wmence it tapers proximally until it is lost in the re-entrant angle above mentioned, at which point it becomes the 200 INJURIES AND DISEASES OF THE SKIN stratum lucidum, to which epidermal layer the nail corresponds. Practically, however, as will be seen later, in the removal of the nail there is an arbitrary area where the comparatively dense substance of the nail becomes a delicate epithelial film. This arbitrary point is a short distance proximal to the free edge of the eponychium, correspond- ing to about the middle of the matrix (see C, Fig. 96). In various pathological conditions, such as in subungual abscesses and subungual hematoma, where the nail has been separated from the nail bed and the nail matrix, the proximal free edge of the nail will be found at this Fig. 94. — Microphotograph of transverse section of the finger through the body of the nail. A, nail; B, nail bed; C, subungual space with dilated bloodvessels; D, shaft of distal phalanx; E, dense corium; F and G, vertical arrangement of trabecular of the subcutaneous tissue; H, sweat glands; /, paronychium ; J , nail sulcus. point and not at the theoretical origin of the nail in the re-entrant angle at the proximal portion of the matrix. The Lunula. — This term is given to the white portion of the nail just distal to the free edge of the eponychium. It corresponds to the visible portion of the nail matrix. The cause of its opacity as compared to the translucent nail body is not quite clear. The reason ascribed is that it is due to an inherent opacity peculiar to the cells of the matrix. The Nail Matrix. — This is composed of the epithelial cells from which the nail grows. Its proximal margin is situated close to the > (X 2 >> cd « -a a> Hi -fi pG CD S3 '3 J** 3 " to +° «n .2 02 03 «J oj 0, oO a CD ;.2H 2 "^ _. cd -£ ? O d a £ 0/ CD Sh ■S-S* 3 .2 co £ +J 6 "H ,.-, 'a a o o 5 S „ | a g += * * a &? 3 en O O 03 i -2 ; ^ j mo ci 3 += a H-l cu a > to CD to += 2- r 1 o g J _ S- _j CD .£ -** to " .a _a tn g •-•£ 2 - ^ ° "5 3 a 5 'o ?^l 1 a 4^ "35 S "? ft 3 a 5 II .2 o H c O a to in CO 0! si sS o"° to k a t- ft--* ^ (B to aj o "^ « a Cm - CO o3 T) !, O. CD S w s -^ - to .y a x co c3 a tt -g S g a rS § ^a a a ~, 1 cc a to o3 jh -£ S c & a 3 3 ■2 e e o a ' '8 Q a a a o ."S M o M CD CO cc is a -^ to >> ■^ o3 a M O — a « "3 S -2 : 5 2 ^ o3 +^ cd a CO o to I CD h cd -3 -S o -j3 53 -a £ _ c3 a += a 5 cd . . ^ cd r o o S r3 -9 8 '-3 ° a o3 +j 4^ jj cu ^ cd —a CO 3 3 '-6 a 3 2 •- » > 2 .s £ 8 o >>^a 2 t-i « tO CC a^J tn O r „ CD O QQ -SSiJ 03 S & a cd x) a o S s i-, ^ c3 at« to 03 « ftGO o DISEASES OF THE SKIN 201 extensor tendon over the base of the distal phalanx, just distal to the interphalangeal joint. It extends distally as far as the lunula. Incision of the nail matrix should almost never be necessary except for excision. Longitudinal incision of the nail matrix is most ill-advised and has been the cause of countless split nails, a permanent and irremediable deformity (see Figs. 97 and 98). Accordingly, in any possible instance where it seems advisable to incise the nail matrix the incision should be made transversely rather than longitudinally. By so doing, an absolute thinning of the nail may result, in most cases unnoticeable, but the deformity of a split nail avoided. The trail bed is confined to that layer of epithelium upon which the nail body rests, from which it derives its nutrition, but from which it does not grow. It is entirely distal to the lunula. This epithelium is thrown into even, longitudinal, papillary ridges. Subungual Space. — This applies to the subcutaneous tissues beneath the nail bed and the nail matrix. It is exceedingly vascular, and in section shows an enormous number of arterioles. It is particularly important with reference to the infections of the eponychium, the paronychium and the dense fibrous tissue of the extreme tip of the finger. Anterior Closed Spaces. — In the thumb there are two, and in the other fingers three, that clinically, and to a certain extent anatomically, may be called closed spaces. The flexion creases of the fingers are the dividing line between the anterior closed spaces. In the fingers they are the distal, the middle and the proximal; in the thumb the distal and proximal. (Plate IV.) The distal closed space is more completely separated from the middle closed space than the middle from the proximal. The reason for this is because of the large amount of space taken up by the head of the second phalanx, the glenoid ligament and the flexor tendons at the level of the distal flexion crease, thus reducing the distance from the skin epithelium to the flexor tendon to a minimum. Certain features of the architecture of these anterior closed spaces demand attention. In the first place the epithelium of the epidermis is exceed- ingly thick. Though there are no hair follicles and sebaceous glands, there are a great many sweat glands which penetrate through the corium into the outer portion of the subcutaneous tissue. The con- nective-tissue trabecule of the subcutaneous tissue separating the fat bundles have a different arrangement from those trabecule belonging to the dorsum of the hand. They tend to run at right angles to the skin in marked contradistinction to the dorsum of the finger where the tendency is to run parallel to the skin (F and G, Fig. 94). These connective-tissue strands are very strong and thick, particularly at the distal end of the anterior closed space of the distal phalanx, where they run directly from the corium to the end of the phalanx. It is inter- esting to note the gradual transition from bone to connective tissue at this point. The middle anterior closed space is the smallest and 202 INJURIES AND DISEASES OF THE SKIN corresponds to the shaft of the middle phalanx. The proximal anterior elosed space is different from the other two because of the freedom with which it communicates with the palm of the hand and the tissues of the web of the fingers. The free edge of the web of the ringers is continuous with their anterior surfaces. Just dorsal to this and along the sides of the fingers there is no flexion crease, nor is there any limiting factor to the extension from the sides of the proximal closed space into the tissues of the web. Along this route run the tendons of the lumbrical muscles and the interossei to be inserted into the phalanx and into the extensor tendons. Close to these tendons run the digital vessels and nerves, and extension along this route of a web abscess of the palm into the proximal closed space and vice versa is a common clinical sequence. The two digital vessels and nerves run along the anterolateral aspect of the fingers. It is true that where they enter the distal anterior closed space they run in rather a constricted portion of the finger, though the sections show that there is more room for them than is generally believed, and that direct pressure as they enter the distal anterior closed space can hardly be a primary factor in cutting off the blood supply to the distal phalanx. It is important to recognize where the digital nerves enter the distal anterior closed spaces, inasmuch as it is often possible to infiltrate near them with local anesthesia in operating on the ends of the fingers. The Glenoid Ligament. — The glenoid ligament is a structure made up of dense bands of interlacing fibrous tissue situated on the anterior surface of the interphalangeal joints and lined on its dorsal surface by the synovial membrane of the joint. Anterior to it passes the flexor tendon which is in intimate relation with, but not firmly attached to it. The strongest attachment of the glenoid ligament is to the anterior surface of the base of the phalanx distally. It is of importance in the mechanism of the posterior dislocation of the phalanges. The Extensor Tendon. — The extensor tendon is flat and more of an aponeurotic sheet than a tendon, is uneven in thickness at different portions of the finger and runs in fascial planes to its insertion on the dorsal surface of the distal phalanx at its base and for a considerable extent along its shaft. It is thickened over the proximal phalanx, where the tendons of the interossei and lumbrical muscles are inserted. It is also thickened over the metacarpophalangeal and interphalangeal joints, where it serves to form a portion of their capsules. This tendon divides the dorsal surface of the finger into two fascial spaces, the first called the dorsal subcutaneous space and the second the dorsal subaponeurotic space, spoken of by Dr. Kanaval in his book on infections of the hand. Finger-end Infections. — Eponychia. — The infections of the epony- chium are generally situated slightly to one side of the midline, are often associated with a paronychia and are commonly called "pan- aritium" or " run-arounds." From a clinical standpoint as well as pathological, it is wise to differentiate two types. The first, or simplest DISEASES OF THE SKIN 203 type of eponychia (Fig. 95), is that type in which the infection is con- fined to the epithelium and subepithelial tissue on the dorsum of Fig. 95. — Diagrammatic drawing to illustrate the superficial type of an eponychia where there is no extension to the subungual space. In this type, no interference with the nail is necessary. Clipping away the "roof" of the pus blister is generally all the opera- tive treatment needed. If this does not suffice, a subungual extension should be suspected. the nail base and has not spread either through, or proximally, or laterally, to beneath the nail matrix so as to form a subungual abscess. This simple type is easily treated by separating the free epithelial edge of the eponychium from the nail so that the superficial pus pocket Fig. 96. — Diagrammatic drawing to illustrate a severer type of eponychia. In this instance the infection has spread to the subungual space either proximal to the matrix or along its side, or directly through it. The nail has become separated from its matrix epithelium, and now forms the roof of a pus blister. It has lost its nutrition and acts as a foreign body in an abscess cavity. All the nail that has separated must be removed before healing will take place. The arbitrary point where the transition occurs between grossly dense nail and delicate stratum lucidum of the epithelium is indicated. This, and not the theoretically proximal extremity of the nail in the re-entrant angle made by the matrix and the reflected epithe- lium of the eponychium, is the proximal free edge of the nail when it separates. Acute flexion of the phalanx often displaces this free edge dorsal to the eponychium, facili- tating removal without incision. A, subungual abscess; B, eponychia; C, proximal free margin of nail after separation. receives adequate drainage. No interference with the nail is necessary in this condition. The second, or more serious type of eponychia, 204 INJURIES AND DISEASES OF THE SKIN is that in which the infection has spread, either through the nail matrix, near its proximal end, or around its proximal or lateral free edge into the subungual space. In this instance, the nutrition of the nail is interfered with and it becomes separated from its matrix. By referring to the diagram (Fig. 96) it will be seen that the nail having separated from the matrix, projects as a free edge, which occurs at an arbitrary line, about half way down the matrix, into an abscess cavity, and acts as an irritating foreign body. Failure to remove that portion of a nail which has separated from its bed or matrix, and has accordingly lost its nutrition, is dead, and is acting as an irritating foreign body, is by far the commonest cause of the long duration of many of this type of finger infection. The diagnosis of a subungual extension is generally made on two points, one in the history — an eponychia or paronychia that refuses to get well, or has had a duration of more than two or three days without treatment. The other point rests upon a very careful inspection of the nail, after cleansing, for any injected appearance of the subungual space through the nail or opacity or inequality in color. It is not infrequent to be able to notice that the lunula is asymmetrical. Tenderness, such an extremely important guide in other respects in finger infections, is of little avail and is of not as much value in diagnosis of subungual abscess as the history and the appearance of the nail. Paronychia. — The same general remarks as to eponychia apply to paronychia, inasmuch as antomically they are very similar. On the other hand, paronychial extensions extend to the subungual space beneath the nail bed, instead of the nail matrix. It may be well to mention a clinical fact at this point, namely, that the association of a paronychia with a distal anterior closed space abscess is a rare con- dition. Paronychias do not easily extend to the anterior closed space, nor do anterior closed space abscesses extend to the paronychium, and many unnecessary incisions have been made either in the paronychium or in the anterior space. Paronychia is almost a constant associate with ingrowing toe-nail. Treatment of Severe Eponychia and Paronychia. — In simple paronychia as in simple eponychia the reflected epithelium should be pushed or separated in any way from the surface of the nail and broken through near its deep attachment. At this point the instrument will open into the abscess. If the abscess in a paronychia has extended beneath the nail along the body of the nail, that portion of the nail edge that has separated from the nail bed and is acting as a foreign body in the wall of the abscess should be removed to the point where the nail is found to be attached to the nail bed. In eponychia and in paronychia where the abscess has extended to the subungual space beneath the nail matrix the so-called paronychial incision will sometimes have to be made. This incision is simply an extension proximally along the lateral nail sulcus with a result that the reflected epithelium of the paronychium or the eponychium, as the case may be, is incised; but DISEASES OF THE SKIN 205 no incision is made through the nail matrix nor through the nail bed at any point (Fig. 97). The nail where it has separated from its epithelium is then removed, and drainage instituted. It is well to note that removal of the base of the nail alone without any incision will suffice in many more cases than is generally supposed. Subungual Space Abscess. — This may occur anywhere underneath the nail and has already been spoken of with reference to eponychia and Fig. 97 Fig. 98 Fig. 97. — Photograph of a cleft nail due to an old injury to the nail matrix. This injury occurred in a postman many years previously. During winter the cleft would extend to the base of the nail and remain wide open; during summer with improvement in the circulation the cleft would almost close. A, "paronychial incision" for parony- chia or eponychia, where an incision is required. This will avoid a "cleft nail." Fig. 98. — Photograph of a cleft nail due to an old injury to the matrix with no apparent scar of eponychium. paronychia. Where it occurs, however, away from these two points, for instance, when caused by a splinter or needle entering the end of the finger just beneath the nail, as is shown in Fig. 99, the nail has been separated from its bed to a varying extent and pus may even be seen through it. Having at this point lost its nutrition the nail is useless and should be removed. In this instance the nail is forming the roof of a blister, and when removed the shiny, glistening nail-bed epithelium will be seen beneath, after the pus has been sponged away. There 206 INJURIES AND DISEASES OF THE SKIN will often, however, be a small spot of necrosis of nail bed epithelium, or it may be of considerable size, leading into an abscess cavity in the subungual space. Accordingly, it will be seen that many of these abscesses are clearly of the collar-button or dumb-bell type, and the rule to always remove the entire roof of a pus blister holds good. It is clinically a fact that a subungual abscess is very rarely associated with bone involvement, with the exception of those which occur at the extreme tip of the phalanx, where the dense connective-tissue fibres are so intimately attached to the tip of the phalanx. Ingrowing Toe-nail. — A so-called ingrowing toe-nail is caused by one or more of the following factors, alone or in combination : High heel, pointed shoes, too short shoes. Pressure on the side of the toe against the lateral edge of the nail causes trauma to the reflected layer of paronychia! epithelium in the nail sulcus. Infection results. ^Yith Fig. 99. — Diagrammatic drawing of a subungual abscess frequently seen where splinters or needles have been run into the end of the finger. In this case the nail, forming the "roof" of a pus blister, is dead, and should be removed wherever it has been separated from its bed, whence it receives its nutrition. Usually after removal of the nail, a small sinus opening can be seen leading through the nail bed epithelium into the subungual space, e. g., a "collar-button" abscess. Removal of the nail is generally enough for drainage. rest and cleanliness the infection disappears, but the trauma may thus be repeated so often and infection follow infection with such rapidity that scarring of the tissues of the paronychium ensues. The paronychium may thus become hyperplastic and considerably larger than normal. There generally is a chronic paronychia. Children outgrowing their shoes may be subjected to this trauma. Close clipping of either of the distal free corners of the nail may also subject the soft parts to trauma against the close cut, partially buried, free edge. Treatment. — The majority of these cases may be permanently cured by cleanliness and advice as to the correct shoe. Occasionally, however, the condition has obtained for such a long time that the architecture of the side of the toe has been distorted to a more or less permanent degree. In such cases operation will give speedy and permanent relief. DISEASES OF THE SKIN 207 Operation for Ingrowing Toe-nail.- -The object of the operation is to permanently narrow the nail. This is done by removing the side of the nail, the nail bed and, most important of all, the nail matrix. A simple way of doing this is indicated in the diagrams (Fig. 100). It is important for one or two days before the operation to clean the field of operation as thoroughly as possible, applying a sterile dressing. After applying a rubber tourniquet and under local anesthetic, prefer- ably novocaine, a slightly curved incision is made along the nail sulcus through the eponychium. This gives a good exposure to the II in Fig. 100. — Operation fur ingrowing toe-nail. I, illustration of a skin incision well adapted to expose the proximal lateral corner of the nail matrix: the matrix epithelium at this ]>"iiit i- sometimes not completely removed, with a consequent failure to effect a permanent cure: o, proximal and lateral corner of the nail matrix. II, the flaps have been dissected back leaving the reflected layer of epithelium from the eponychium and the paronychium attached to that portion of the nail to be removed. The nail, the nail bed. and the nail matrix corresponding to the shaded area are excised as one piece. Thus granulating surfaces of the flaps come in contact with the granulating surface of the subungual space. 777, after the excised tissues have been removed, the flaps, with their raw surfaces against the exposed subungual space, fall together as indicated. Observe that the oblique incision of the matrix should theoretically cause the permanent, lateral, nail edge to resemble the normal " chisel edge" shape of the normal nail, thus causing a gradual transition between the nail edge and skin epithelium: a, area of nail left for temporary protection, that will ultimately disappear: b, nail growing from this portion of matrix very thin; c, nail growing from this portion of matrix thicker; d, nail growing from this portion of matrix normal thickness. proximal and lateral corner of the nail matrix. The corresponding eponychial and paronychial flaps are liberated with a knife in such a way that their reflected layers of epithelium will be left on that portion of the nail subsequently to be excised. This leaves a granulating surface to come in contact with the granulating surface exposed after resection of the nail, its bed and its matrix. The latter are removed by an oblique incision extending from the distal corner of the nail through the matrix nearer the median line. It is possible to be sure that all the matrix epithelium has been removed if a small amount of 208 INJURIES AND DISEASES OF THE SKIN areolar tissue be seen with its accompanying fat outside of the proxi- mal corner. Should this proximal corner of matrix epithelium be left, the wound will either not heal or there will be a recurrence of the original condition through the growth of the nail from the remaining portion of matrix. The flaps may then be sutured with one very fine silkworm-gut suture, the tourniquet removed and gentle pressure made to control the hemorrhage before permanent dressing is applied. After a short time the bleeding will practically stop. Distal Anterior Closed Space Abscess. — This is the lesion generally spoken of as a felon. It is one of the commonest places for a "collar- button abscess." The collar-button abscess in this instance is a superficial pus blister communicating by a small sinus through the epidermis and corium with a deeper abscess in the subcutaneous tissue (Fig. 101). Fiu. 101. — "Collar-button" abscess of the anterior closed space. The pus blister may be large and the deep abscess small, as in this diagram, or vice versa. There may be more than one sinus between the blister and abscess. A, deep abscess; B, sinus; C, pus blister; D, so-called "roof" of the pus blister. The pus blister may be large and the abscess small, or nice versa. Many times these abscesses are incompletely opened simply because the rule to remove the whole of the roof of a pus blister has not been observed, and the small sinus leading into the real abscess has been overlooked. Always remove the whole roof of a pus blister. Several sinuses may open under the roof of one pus blister. After the removal of the roof of the blister the real abscess in the cellular tissues may then be drained. In abscess formation of the anterior closed space it is the fat bundles that earliest liquefy, and it is in these cavernous spaces walled off from one another by the strong bands of connective tissue running perpendicularly from the skin in which pus accumulates. The connective tissue separates later with difficulty. Careful study of the area of tenderness is the best guide to the size of the cavity and method of treatment. The commonest complication of an anterior closed space abscess is infection of the bone of the distal phalanx. It is very rarely associated with paronychia and eponychia or subungual abscess, but may become so through neglect or injudicious incision. DISEASES OF THE SKIN 209 Treatment. — Certain collar-button abscesses have a very small, deep abscess. If the area of tenderness has been small and after completely removing the blister roof a probe gently introduced through the sinus evacuates only a drop or so of pus, chemical drainage by the use of pure carbolic is indicated. This is done in the following manner. The pure carbolic crystals, liquefied by heat, are used, weaker solutions being less efficacious. It is applied on the end of a pointed wooden toothpick directly into the sinus opening. After the anesthetic action is noted a gradually increasing circular motion about the wall of the sinus will coagulate and shrivel up the tissues so as to enlarge the lumen and secure adequate drainage. Care must be taken to penetrate the corium and really enter the abscess. Disregard of this has caused Fig. 102. — Diagrammatic drawing illustrating the lateral incision into an abscess of the anterior closed space. Observe that the subcutaneous tissue trabecular are cut across, allowing free drainage of both the deep and superficial fat bundles. The point of the knife should be directed more towards the surface than towards the deeper structures, to avoid injury of main bloodvessels. many failures. The deep wall of the abscess should not be traumatized. Small gutta-percha tissue drains with or without small pieces of cotton tape or string dipped in pure carbolic and excess removed are cut to fit the size of the sinus and inserted into the abscess. Outside of this is placed the dressing. In the treatment of larger abscesses incision in the midline should be avoided if possible. It should be made along the side of the anterior closed space (Fig. 102). The question arises as to where to make the incision in those cases, and they are quite frequent, in which there is a collar-button infection and sinus in the midline of the finger. In an abscess of any size it is better to disregard the collar-button sinus entirely and make the usual lateral anterior closed space incision into the abscess from the side. After so doing the sinus of the collar-button infection epithe- 14 210 INJURIES AND DISEASES OF THE SKIN lializes across rapidly with a minimum amount of scar for the pulp of the finger. Abscess of the Distal Anterior Closed Space, with Osteomyelitis of the Distal Phalanx. — There are several theories elaborated to account for the frequency of bone infection in distal anterior closed space abscesses. On examining a series of sections made in the lateral plane of the finger, the blood supply of the distal phalanx can be seen to be derived from branches of the two digital vessels that unite as an arch just proximal to the thickened tip of the phalanx. From this arch run smaller branches through definite openings in the shaft. Proximal to these openings the anterior surface of the phalanx is covered by the insertion of the flexor profundus tendon. No openings of such magnitude are to be observed on the dorsum of the bone. Through these openings infection may readily extend directly into the medullary cavity of the diaphysis (Fig. 103). It is at precisely this Fig. 103. — Diagrammatic drawing of an abscess of the anterior closed space, with osteomyelitis of distal phalanx. Note that that portion of the bone most frequently and most extensively involved is near the entrance of the bloodvessels to the diaphysis. This is what is commonly known as a " bone felon." A, point of entrance of diaphyseal bloodvessels. point that necrosis of the bone is most frequent. The proximal or epiphyseal end of the bone, on the other hand, is supplied by branches which come from the main digital vessels at the level of the joint. These branches run between the tendon, the distal end of the glenoid ligament and the bone, entering the bone as tiny vessels just distal to the insertion of the capsular ligament. These vessels are separated from an abscess of the anterior closed space by the flexor tendon and the glenoid ligament. Infection of the epiphyseal end of the phalanx is therefore generally associated either with an infection near the joint or a neglected anterior closed space infection Avith osteomyelitis and direct extension along the medullary cavity of the diaphysis. In these cases there is generally an extension of the infection into the joint. An interesting type of finger infection in neglected and untreated felon cases has been observed. These cases have acted so similarly DISEASES OF THE SKIN 211 that it seems justifiable to characterize them as a type. The process starts as a severe anterior closed space abscess; later there is bone infection of the diaphysis extending to the epiphysis, thence extending to the interphalangeal joint. Besides these lesions there is a dorsal abscess over the posterior surface of the joint (Fig. 104). This dorsal abscess simulates in many ways an eponychia complicated with subungual abscess. The mistake of considering it such is easy to make and an unnecessary paronychial incision may be made. The course of the infection is clear with the exception of the dorsal abscess. By what route this extension to the dorsum occurs is hard to say. It is probably through the joint. Its situation is in the subcutaneous space over the joint and dorsal to the extensor tendon. In the regeneration of bone following osteomyelitis of the distal phalanx, osteogenetic cells are often found along the dorsum and the sides of the shaft, especially near its proximal end where the two Fig. 104. — Diagram of a type of anterior closed space abscess, with osteomyelitis of the terminal phalanx, suppurative arthritis of the distal interphalangeal joint, with dorsal abscess over the joint. The dorsal abscess should be differentiated from an eponychia with subungual abscess. tendons, extensor and flexor, are inserted. Where practically the whole of the diaphysis has sequestrated the radiograph may show only the faintest streak along the dorsum; but two or three months later a radiograph may show extensive regeneration of bone forming a phalanx of almost normal size. The greatest care should be taken to preserve intact as much of the tissues surrounding a sequestrated piece of bone as possible. Suppurative Arthritis of Interphalangeal and Metacarpophalangeal Joints. — These infections are due to wounds into joint, extensions from neighboring infections, and, in the metacarpophalangeal joint, often from a laceration produced by the blow of a closed fist against teeth. Though these infections are generally staphylococcic in origin, those caused by a blow against teeth may be infected by various organisms indigenous to the mouth cavity that may cause a persistent and very foul necrosis. The treatment should be conservative. Drainage should be established, if possible through the wound, or by 212 INJURIES AND DISEASES OF THE SKIN an extension preferably to one or both sides of the extensor tendon. The whole finger should be immobilized by a splint in extension. By traction over the end of the splint with an elastic extension appa- ratus, thus keeping the ends of the bone apart, by the careful removal of small sequestrated pieces of bone or cartilage, by the use of the silver nitrate stick and pure carbolic along sinuses in which exuberant granulations are prone to block drainage, anchylosis often may be avoided and a limited degree of motion be preserved,. Abscess of the Middle Anterior Closed Space. — The treatment of these abscesses should be by an anterolateral incision on whichever side of the tendons the abscess is worse. Should the abscess involve the whole of the middle anterior closed space, it is better to make an anterolateral incision on either side rather than to try to drain across the tendons. This, however, is not as often necessary as it is in the abscess of the proximal closed space. Abscess of the Proximal Closed Space. — These abscesses are often associated with subcutaneous abscesses at the base of the finger in the palm, or with web infections between the affected and contiguous fingers. The diagnosis from digital tenosynovitis is sometimes difficult, but absence of exquisite tenderness over the tendon sheath in the second phalanx will generally eliminate a tendon sheath infec- tion. Anterolateral incision, such as has been described in middle anterior closed space abscesses, should be made. Particular care should be taken, however, not to continue the incision through the flexion crease into the palm, inasmuch as a serious contracture of the finger may result. This is true to a certain degree of the other two closed spaces, but particularly true here. Subcutaneous Abscesses at the Base of the Fingers and Web — Abscesses of Palm.— It is important to understand the arrangement of the palmar fascia in dealing with these abscesses. Starting from the palmaris longus and its attachment in the lower edge of the annular ligament, it spreads out distally, fusing with the deep fascia covering the thenar and hypothenar muscles on either side. It is well to think of it as made up of anterior fibres that run longitudinally and corre- spond to the fibres of the palmaris longus and posterior fibres that run transversely of obliquely and correspond to the fibres of the annular ligament (Fig. 105). The longitudinal fibres run in four slips to the bases of the four inner fingers. The arrangement of the trans- verse and diagonal fibres is more complex. At the level of the meta- carpophalangeal joint, and just proximal to it, is the transverse meta- carpal ligament (Fig. 106, C) made up of a band of transverse fibres about 1 cm. broad that is just superficial to the proximal ends of the digital tendon sheaths. On either side of the flexor tendons run slips that fuse with the deep palmar ligament which is the distal margin of the aponeurotic-like fascia covering the palmar aspect of the interossei and inserted into the sides of the heads of the metacarpals, acting as an interosseous ligament. Between the tendons at this level there is DISEASES OF THE SKIN 213 a space bounded anteriorly by the transverse metacarpal ligament, posteriorly by the deep palmar ligament covering the palmar interossei, and on either side by slips from the transverse metacarpal ligament to the interosseous fascia, containing the digital vessels and nerves and the lumbrical muscles (Fig. 106). More distally, to form the web of the finger, run other transverse fibres that fuse with the free interdigital edge of the dorsal aponeurosis Fig. 105. — Illustration from Poirier, showing the palmar fascia. Observe that the longitudinal fibres corresponding to the palmaris longus tendon are superficial and the deep fibres corresponding to the annular ligament are transverse. A, four longitudinal slips; B, transverse fibres forming a part, of superficial palmar interosseous ligament; C, transverse metacarpal ligament; D, palmaris longus. to form the superficial palmar ligament with insertion into the sides of the bases of the neighboring proximal phalanges just anterior to the lumbrical tendon. Corresponding to the same plane as the palmar fascia are the so-called ligamenta vaginalia of the fingers. These are diagonal and transverse fibres, scarcely noticeable over the joints but very thick and strong over the shafts of the phalanges, binding the flexor tendons and their sheaths to the phalanges and preventing prolapse on flexion. They 214 INJURIES AND DISEASES OF THE SKIN are practically annular ligaments and will be termed the phalangeal annular ligaments. It is not uncommon among men who work with shovels or tools that cause trauma to the palm of the hand to have abscesses that often develop beneath callous spots at the base of the fingers. They are tender and cause considerable pain but often show very few surface signs. Occasionally there is a pus blister involving the calloused epidermis. They occur either over the tendon or between the fingers, or both. The important feature to recognize is that they may exist on both sides of the palmar fascia, which in this instance is largely Fig. 106. — Diagrammatic drawing of the fascial compartments of the hand at the level of the transverse metacarpal ligament, to illustrate the situations and extensions of subcutaneous and web abscesses of the palm. A, flexor tendons in their sheaths; B, longitudinal slips of the palmar fascia to the four inner fingers; C, transverse meta- carpal ligament with prolongations to the sides of metacarpal bones fusing with the deep palmar interosseous ligament; D, digital vessels and nerve; E, dorsal epidermis; F, fascia covering the interosseous muscle which, slightly distal to this point, becomes the deep palmar interosseous ligament; G, lumbrical muscle in its canal; H, subcu- taneous tissue showing the dense trabecule running from the palmar fascia to the corium; /, palmar epidermis. made up of the transverse metacarpal ligament, and in this way may be of the "collar-button" or "dumb-bell" type. By reference to the diagrams (Figs. 106 and 107) it may be seen that such an infection may pocket: (1) As a pus blister in the epidermis; (2) as an abscess in the subcutaneous tissue; (3) as an abscess between the transverse meta- carpal ligament and the tendon sheath; (4) as an abscess between the tendons in the space occupied by the lumbrical muscles and digital vessels; (5) distally in the tissues of the web and (6) exceptionally on the dorsum of the hand, probably along the course of the anterior perforating vessels, or by direct extension from the web. DISEASES OF THE SKIN 215 Treatment. — Treatment of those abscesses directly over the tendon and confined to the subcutaneous tissues should be by incision over the maximum point of tenderness, avoiding the flexion crease separat- ing the palm from the proximal phalanx. A good light and retraction are of use in tracing and adequately draining the many pockets that may occur in this type of infection. Should the maximum points of tenderness be on either side of the finger, incision should be made in the web, directly between the fingers, and if the abscess extends to the dorsum the web may be cut through. It is unwise, however, to make a web incision communicate with the anterolateral incision of the proximal closed space, owing to the severe form of contracture Fig. 107. — Diagrammatic drawing of the fascial compartments of the hand at the level of the transverse metacarpal ligament, to illustrate the situations and extensions of subcutaneous and web abscesses of the palm. A, extension in subcutaneous tissue between tendons; B, two routes of extension into lumbrical canal; infection in this space extending proximally enters the thenar or mid-palmar space; extending distally, may enter the proximal anterior closed space; C, extensor tendons; D, dorsal aponeurosis; E, interosseous muscles; F, extension beneath transverse metacarpal ligament about tendon sheath; G, collar- button abscess; H, pus blister. liable to result. These incisions had better be made separately and a small bridge of tissue left between. Tendon Sheath and Fascial Space Infection. — It cannot be too strongly urged that anyone contemplating treating hand infections, and in particular those dealing with the tendon sheaths and fascial spaces, should study the work of Dr. A. B. Kanavel on "Infections of the Hand." Particularly important is it that a clear understanding of the surgical anatomy of the tendon sheaths and fascial spaces be had. The accompanying diagrams of Dr. Kanavel show eight sections of the hand made about 1 cm. apart. The three flexion creases of the palm should be noted as superficial landmarks (Fig. 108). The first 216 INJURIES AND DISEASES OF THE SKIN diagram (Plate V, Fig. 1) shows the flexor tendons in their synovial sheaths at the level of the shafts of the proximal phalanges. Two fascial spaces, the dorsal subaponeurotic space and the dorsal subcutaneous space are shown. The subcutaneous space is that fascial space that is separated from the subcutaneous areolar tissue by the superficial layer of the dorsal aponeurosis. The digital vessels and nerves are seen along the anterolateral aspects of the fingers. In the second diagram (Plate V, Fig. 2) appear the tendons of the lumbrical muscles, and the interosseous muscles. It is important to note the close proximity of the lumbrical muscles to the digital vessels and nerves. It is along the digital Fig. 108. — Drawing made from specimen showing sites of the various sections taken through the hand. (Kanavel.) vessels and the lumbrical muscles that infections travel to the deep fascial spaces of the hand, later to be described. The third diagram (Plate VI, Fig. 1), at the level of the distal ends of the metacarpal bones shows the dorsal aponeurosis including the extensor tendons separating the dorsal subcutaneous from the dorsal subaponeurotic space and its relation to the fascial planes investing the interosseous muscles. The flexor tendons are still enclosed in their digital synovial sheaths, and the lumbrical muscles with the vessels are shown on the radial side of the fingers to which they belong. In the fourth diagram (Plate VI, Fig. 2) the dorsal fascial spaces on either side of the extensor tendons are broadening out on the back of the hand, later PLATE V Fig. 1. — Cross-section No. I. — DSAS, dorsal subaponeurotic space; DV and iV, digital vessels and nerves; ECT, extensor communis tendon; FT, flexor tendon; PP, proximal phalanx; SCS, subcutaneous space; SS, synovial sheath. (Kanavel.) jDSAb IM EPP FT DV—N LM Fig. 2. — Cross-section No. II. — Through epiphysis of proximal phalanx. DSAS, dorsal subaponeurotic 'space; DSCS, dorsal subcutaneous space; DV and N, digital vessels and nerves; ECT, extensor communis tendon; EPP, epiphysis proximal phalanx; FT, flexor tendon; IM, interossei muscles; LM, lumbrical muscle; SS, synovial sheath. (Kanavel.) PLATE VI EOT X>SCd DSA'b MB DT SB Fig. 1. — Cross-section No. III. — Proximal to metacarpophalangeal joint. DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; DT, dense fibrous tissue; DV and N, digital vessels and nerves; ECT, extensor communis tendon; FT, flexor tendon; IM, interossei muscles; LAI, lumbrical muscle; MB, metacarpal bone; SB, sesamoid bone; SS, synovial sheath. (Kanavel.) ECT V DSAS DSCS DT D6 Fig. 2. — Cross-section No. TV. — -Two cm. proximal to joint. ATP, adductor trans- versa pollicis; DB, digital branch, DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; DT, dense fibrous tissue; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; FT, flexor tendon; IAI, interossei muscles; LM, lumbrical muscle; M, metacarpal bone; MFC, middle flexion crease; MPS, middle palmar space; RI, radialis indicis; SS, synovial sheath; TS, thenar space. Note the beginning of the middle palmar space. (Kanavel.) PLATE V D5C3 B1M M DSA5 ECT T5 ATP fLP Fig. 1. — Cross-section No. V. — 3| cm. proximal to joint. ATP, adductor trans- versa pollicis; DIM, dorsal interosseous membrane; DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; FT, flexor tendon; HM, hypothenar muscles with intermuscular spaces: IM, interossei muscles: IS, space between adductor trans- versus and first dorsal interosseous: IV, interosseous vessels and nerve; LM, lumbrical muscle: M, metacarpal bone: MPS. middle palmar space; PIM, palmar interosseous membrane: RI, radialis indicis; TS, thenar space: UB, ulnar bursa: UV and .V. ulnar vessels and nerve; V, vein. (Kanavelj Fig. 2. — Cross-section Xo. VI. — Through distal part of thenar area. ATP, adduc- tor transversus pollicis: DIA. dorsalis indicis artery; DP A. deep palmar arch — digital branches beginning; DSAS, dorsal subaponeurotic space; DSCS, dorsal subcutaneous space; ECT, extensor communis tendon; FLP, flexor longus pollicis in its synovial sheath; HM, hypothenar muscles with intermuscular spaces; IM, interossei muscles; ITS, indefinite thenar spaces; IS, space between adductor transversus and first dorsal interosseous: LM, lumbrical muscle: MA and N, median artery and nerve: M, meta- carpal bone: MPS, middle palmar space; PF, palmar fascia: PIM, palmar interosseous membrane; 7*.S - , thenar space; TM, thenar muscles; TMF. tendon of middle finger; UV and -V. ulnar vessels and nerves. (Kanavel.t PLA lb VIII UB FT Fig. 1. — Cross-section No. VII. — DSAS, dorsal subaponeurotic space; DSi S dorsal subcutaneous space: ECT. extensor communis tendon; FLP, flexor longus pollicis in ita synovial sheath; FT, flexor tendon: MM, hypothenar muscles with intermuscular spaces; IS, space between adductor transversus and first dorsal interos- seous: M, metacarpal bone; MX and T", median nerve and vessels; MPS. middle palmar space; RA, radial artery; SS, synovial sheath: TM. thenar muscles: TS, thenar space; UB, ulnar bursa; UV and .V, ulnar vessels and nerve. (Kanavel.) DbCS ECRB ecu iPTP Fig. 2. — Cross-section Xo. VIII. — DSCS, dorsal subcutaneous space; EC, extensor communis; ECRB, extensor carpi radialis brevior; ECRL, extensor carpi radialis longior; ECU, extensor carpi ulnaris; EMD, extensor minimi digiti; EPTP, extensor primi internodii pollicis; ESIP, extensor secundi internodii pollicis; FLP, flexor longus pollicis in its synovial sheath; HM, hypothenar muscles with intermuscular spaces; MX and V, median nerve and vessels; PL, palmaris longus; PMPS, prolonga- tion of middle palmar space; RV and N, radial vessels and nerves; SS, synovial sheaths; TM, thenar muscles; UB, ulnar bursa; UV and N, ulnar vessels and nerve. (Kanavel.) DISEASES OF THE SKIN 217 to become fused. The lumbrical muscles are approximating the ten- dons from which they have origin. The distal margin of the adductor transversus pollicis muscle is shown. The level of the section repre- sented by this diagram corresponds to an imaginary line drawn from the proximal end of the distal flexion crease of the palm to the distal end of the mid-flexion crease. This landmark represents the distal boundary of two fascial spaces that are of great importance in the surgery of the hand. They are situated just behind the flexor tendons and in front of the interossei and adductor muscles of the thumb. They are separated from one another mesially along the metacarpal bone of the middle finger from which the adductor transversus muscle takes origin. The mid-palmar space is on the ulnar side and the thenar space is on the radial side. One of the most important facts to remember about these spaces is their close relation to the lumbrical muscles and the branches of the digital vessels. As will be seen later, not only do these spaces become infected along these lumbrical muscles, but the lumbrical muscles are a guide for drainage. Plate VII, Fig. 1, shows the fusion of the dorsal subcutaneous space as well as the dorsal subaponeurotic. The flexor tendons no longer are invested by synovial sheaths, with the exception of the tendon to the little finger and the flexor longus pollicis. The lumbrical muscles taking origin from the flexor profundus tendons lie close to the niid- palmar and thenar spaces that now have extended laterally so as to cover most of the breadth of the hand. The space between the adductor transversus and the first dorsal interosseous is a third fascial space in which abscesses, sometimes communicating with the thenar space, sometimes not, are frequent. It will be later seen how simple it is to drain both of these spaces, if necessary, through the same incision (Fig. 114). Plate VII, Fig. 2, shows the extensor tendons still without synovial investment, the deep palmar arch penetrating the hand as the ulnar artery through the cleft between the adductor transversus and adductor obliquus muscles to the space between the adductor trans- versus and the first dorsal interosseous, then to join the radial artery as it penetrates between the two heads of origin of the first dorsal interosseous. Through this cleft, and probably along the route of this vessel, infection may extend from a thenar space abscess to the space between the thumb adductors and the first dorsal interosseous. At approximately this level originate the two exceedingly important synovial bursas, known as the ulnar and radial bursa?. In the normal arrangement of the digital synovial sheaths of the little finger and thumb there is a constriction that in about one-third of the cases is complete, but in two-thirds is partial, just proximal to the metacarpo- phalangeal joint (Figs. 109-111). Proximal to these constrictions are the ulnar and radial bursa?. The tendons are projected into the ulnar bursa from the radial side, and, as described by Poirier, often divide the bursa into three compartments. Passing beneath the 218 INJURIES AND DISEASES OF THE SKIN annular Ligament, the upper margin of which corresponds to the level of the distal flexion crease at the wrist, it extends anterior to the pronator quadratus muscle for a distance of about 3 cm. The radial bursa investing the tendon of the flexor longus pollicis between the adductor obliquus and the flexor brevis pollicis extends beneath the branches of the median nerve to the thenar muscles just distal to the lower margin of the annular ligament, then runs beneath the annular liga- ment in the >ame plane with the ulnar bursa and to about the same Fig. 109. — The fetal type. (Poirier.) level. These bursa 3 communicate, as a rule, about the lower level of the annular ligament. The arrangement of the synovial sheaths to the flexor tendons of the index and middle fingers may vary and indi- vidual so-called accessory sheaths (Figs. 110 and 111) may be present, which, however, are so close to the ulnar and radial bursae that by either direct communication or by contiguity infections from one bursa generally spread very rapidly to the other. Plate VIII, Fig. 1, shows the extensor minimi digiti in a synovial sheath. The mid-palmar and thenar spaces are narrowed and close DISEASES OF THE SKIN 219 together beneath the tendons. The flexor longus pollieis is in the radial bursa. The flexor tendons are in the ulnar bursa, with the median vessels and nerves just beneath the annular ligament. The radial artery from the back of the hand is passing between the two heads of the first dorsal interosseous. Plate VIII, Fig. 2, shows all the extensor tendons in their synovial sheaths, the thenar and mid-palmar spaces in close contiguity and the flexor longus pollieis in closer relation to the accessory sheaths and ulnar bursa investing the other flexor tendons. Fig. 110. — A normal adult type. (Poirier.) In the tendon sheaths of the fingers it is important to recognize that there are certain places much more exposed to injury and infection than others. Over the interphalangeal joints the dense transverse fibres, corresponding to the deep layers of the palmar fascia prolongations, which may be termed the phalangeal annular ligaments, but which technically are termed in textbooks ligamenta vaginalia, are absent, and the anterior surfaces of the sheaths are 220 INJURIES AND DISEASES OF THE SKIN much closer to the skin and more unprotected than over the shafts. Accordingly, penetrating wounds of the fingers at this point much more readily infect the sheaths than elsewhere. Abscesses developing over the thenar or hypothenar eminences may or may not extend beneath the deep fascia. They do not involve complicated or particularly important tissues and are localized and treated as similar abscesses in any other part of the body. Sub- Fig. 111. — A very frequent adult type. (Poirier.) cutaneous abscesses on the dorsum of the hand are more frequently found on the ulnar side, due to the fact that this side of the back of the hand is more frequently exposed to friction trauma. Relation of the Digital Tendon Sheath Infections to the Thenar and Mid-palmar Spaces.— The lumbricals are inserted on the radial side of the extensor tendons. Accordingly, infections travelling along the lumbrical muscles to the little and ring fingers generally extend into DISEASES OF THE SKIN 221 the mid-palmar space. Those that occur in the canals to the middle and forefingers extend to the thenar space. In digital tendon sheath infections, extensions of infection from the little and ring finger are into the mid-palmar space; from the thumb and forefinger into the thenar space; from the middle finger more frequently into the mid- palmar space, occasionally into the thenar space, sometimes into both spaces. Extensions of infection of the ulnar bursa below the wrist are into the mid-palmar space, from the radial bursa below the wrist into the thenar space. Extensions of Infection from the Ulnar and Radial Bursae and the Fascial Spaces above the Annular Ligament. — Between the radial and ulnar bursae and the tendons they invest above the wrist-joint and the pronator quadratus muscle is a potential space corresponding in its fascial planes with the mid-palmar and thenar spaces of the palm. Beneath the annular ligament these two palmar fascial spaces either directly communicate or are in such close contiguity that an extension of infection from one may occur in the other. Should the process go further up the arm it will extend to the potential space in front of the pronator quadratus muscle, thence extending along the deep intermuscular planes, generally close to the ulnar artery and veins. Less often it may extend along the radial vessels. Should an infection of the radial or ulnar bursae extend above the annular liga- ment it may secondarily extend to this same potential space in front of the pronator quadratus. It is important to know when the infection occupies this space, inasmuch as drainage from the side just in front of either the radius or ulna and the pronator quadratus, behind the radial or ulnar vessels and the tendons of the hand, can be established without injury to the flexor tendons and their sheaths. Secondary Extensions of Tendon Sheath Infections. — By studying Plate IV, or the drawings in Dr. Kanavel's book, the usual extensions occurring in tenosynovitis are evident. The proximity of the tendon sheaths to the proximal end of the middle phalanx and the blood- vessels supplying the bone, as can be seen in sections, give a probable reason why an infection of this phalanx is so much more common than infections of the bone elsewhere. Extensor Tendon Sheaths. — It is extraordinary how frequently one hears of reference to the extensor tendon sheaths on the back of the fingers. There are none. The extensor tendons are invested with synovial sheaths, beneath the dorsal annual ligament, and for a short distance distal to it. The sheath of the extensor minimi digiti tendons extends further distal ly than the others and has been seen to extend almost to the head of the fifth metacarpal. Suppurative infections of these sheaths are comparatively rare and are generally due to an infected wound or extension from a neighboring abscess. Chronic infection of these sheaths due to tuberculosis, or not infre- quently from some other type of infection the nature of which it is not easy to ascertain, are much more common. 222 INJURIES AND DISEASES OF THE SKIN Diagnosis of Infections of Fascial Spaces and Tendon Sheaths. — It is only by constantly examining hand infections as seen in an out- patient clinic that the shades of difference in tenderness and its location, and the interpretation of the value of the different diagnostic signs, that skill in diagnosis of hand infections can be obtained. Of vast importance is an accurate knowledge of the anatomy of the various structures. There are certain fundamental signs that are of great assistance, however, but it cannot be too strongly impressed on the minds of students, or those inexperienced in this type of surgery, that the compact arrangement of so many different kinds of important tissues, all beneath a very dense covering of epidermis, make accurate diagnosis, even with prolonged experience, exceedingly difficult. Tenosynovitis. — By far the most important sign is tenderness sharply defined to the anatomical limits of the suspected sheath. This tenderness is often so localized that with the finger over the same area of skin, pressure in one direction may be comparatively painless and pressure in the opposite direction may cause exquisite pain. In early cases pressure on the sides of the phalanx may be painless, but pressure just in front of the bone, exerted by grasping the anterior closed space between two fingers close to the bone, may cause great pain. This may aid in differentiating it from cellulitis. In the web abscesses of the palm there may be tenderness over the sheath in the palm, and even over the proximal phalanx, due to the associated cellulitis, but absence of tenderness over the sheath at the second phalanx may greatly aid in excluding a sheath infection. In infections of the radial and ulnar bursa? they are frequently associated, and tenderness over the sheath of the little finger and thumb at the same time, even though the degree of tenderness in the palm may be questionable, is almost pathognomonic. In these cases tenderness over the annular ligament may be slight but marked just above it when the infection has extended into the forearm. Active and Passive Limitation of Extension of the Finger. — This sign implies flexion of the fingers. It is important in making the passive extension test to very gently extend the finger as far as possible without pain, holding it between two fingers of the left hand at the sides of the second phalanges. By then bringing the terminal phalanx to full extension with the other hand, and thus putting the flexor profundus tendon of that finger on the stretch without moving the other structures of the finger, passive extension may give valuable evidence in confirm- ing a sheath diagnosis. The customary way of extending the whole finger causes pain in many other types of finger infections that do not involve the sheath, owing to the traction exerted on the inflamed tissues. It should be remembered that the range of motion of the tendons at the proximal end of the digital sheaths is greater than in the finger, where their insertions are placed. Accordingly, the preputial folds which show so markedly at the proximal limits of the digital sheaths DISEASES OF THE SKIN 223 indicate that point where the cavity of the tendon sheath is greatest. It is a clinical fact that in incising a sheath that contains pus, by far the greatest amount is found over the metacarpophalangeal joint. It is also true that the signs of tenderness on pressure and pain on extension are chiefly referred to this point. These two signs combined with the history of the case which may give some indication as to the probability of the sheath being involved, are the main points to be relied upon for diagnosis. If the anatomical structures contiguous to the sheaths are already understood, the probabilities of infection by extension can also be intelligently considered. Swelling is of prac- tically no value in early diagnosis, nor do the general symptoms play an important role. Treatment. — The only treatment for an acute suppurative tenosyno- vitis as soon as the diagnosis is made is immediate operation. It is in those cases that may have had an injury of perhaps a few hours and present themselves with moderate tenderness limited to the sheath area and with beginning pain on extension, in which surgical judgment is difficult. Many do get well by placing the whole hand absolutely at rest in a moulded plaster of Paris or simple basswood splint after thorough cleaning of the wound and surrounding areas, with rest in bed, catharsis and hot applications. Such a case should be carefully watched and unnecessary pressure over the sheath, for instance, by having all the members of the house staff and a large group of students elicit local tenderness, should be avoided. It is always risky post- poning operative procedures with these signs. Should there be nothing more than sero-pus in the sheath at operation, there is no reason why perfect function should not be regained. Accordingly, it is wiser, if there are distinct local signs, to give the patient the benefit of the doubt, and operate. It is only by doing so early that a stiff finger can be avoided. Unless there is necrosis of tendon, the function, in the infections of the radial and ulnar bursa? is, as a rule, preserved. On the other hand, infections of the digital sheaths are quite different, and preservation of function is much rarer, in fact, it is not preserved as a rule. This is chiefly because the patients are seen rather late in their course, after the nutrition to the tendons has been cut off, so that necrosis has begun and dense adhesions with obliteration of the synovial cavity are practically inevitable. Operative Procedure. — There should be good light, a tourniquet, and in practically all cases, general anesthesia. A tourniquet can be made from an arm band used in one of the various types of blood-pressure apparatus. Small retractors should be used and the incisions placed with a view toward preventing subsequent contractures. On the fingers the skin incisions should be between the flexion creases. They should be just to one side of the median line. They should not be at the extreme side nor should they be in the median line. The advantage of placing the incision at this point can readily be seen when the position of the digital vessels is noted. The branches from these 224 INJURIES AND DISEASES OF THE SKIN vessels to the sheaths run close to the bone and enter the sheath from its dorsal aspect. An incision from the side being carried dorsally to the vessels would cut these branches. If carried anterior to the vessels would submit the main trunks to the chance of pressure necrosis. The incision of the sheath should therefore be at its anterolateral aspect, and the most direct course to it is through the incision in the skin as specified (Fig. 112). The greatest care and a small delicate instrument should be used in incising the sheath so as not to Fig. 112 Fig. 113 Figs. 112 and 113. — Photographs showing the postoperative functional result of an acute suppurative tenosynovitis of the ring finger about three weeks after the operation. The location of the skin incisions are here shown. Cross nick in flexion crease giving freer drainage by marked relief of skin tension. It leaves no visible scar. See scars on ring finger, where this was done. The incisions for infections of the radial and ulnar bursa? below the wrist are also shown. touch, if possible, the tendon and its own "visceral" synovial invest- ment. By not incising in the midline, the obliteration of dead space is easier after drainage has been sufficient, and the gaping of the wound is distinctly less. Much has been written about the skin incisions. The method of incising the sheath is of just as much importance, if not more. In the fingers the annular ligaments binding the tendons to the phalanges should be cut for almost their whole extent. The proximal portions of these ligaments if left uncut, even though it be DISEASES OE THE SKIN 225 for a distance of two or three mm., will not interfere with drainage, and yet serve to prevent the tendon prolapse. It should be remem- bered that the middle flexion crease is directly over the adjacent interphalangeal joint with the finger flexed but slightly distal to it on extension. Accordingly, in incising a digital sheath of the middle finger, for instance, one would open the sheath near the distal inter- phalangeal joint, where its coverings are slight, and extend along the phalangeal annular ligament almost to the proximal interphalangeal joint; then through the incision in the proximal closed space, the unprotected portion of the sheath at the proximal interphalangeal joint should be incised and the phalangeal annular ligament to the full extent of the proximal closed space. This will leave its proximal portion, which is in the palm, intact. Through an incision in the palm directly over the sheath and through the transverse metacarpal ligament the sheath should be opened all the way to its proximal extremity through an adequate incision. Many things are used for drainage, some of them are gutta-percha tissue, rubber sheeting, such as a piece cut from a surgical rubber glove, gauze, or a bit of folded thin China silk soaked in vaselin or alboline or camphor- carbolic-alcohol solution (see above); a cellulose tissue capable of boiling, known as "Flexoid," which is very soft and pliable, recom- mended by Dr. Donald Gordon of New York, and in many ways an excellent substitute for a gutta-percha tissue, etc. Whatever is used should be applied with the following precautions: Drainage should be to the opening in the sheath and not pressing in any way so as to cause necrosis, but not into the sheath. It should not protrude above the level of the skin, but to it, so that there will be no pressure of the dressing on the drain itself. Rubber tubing should be condemned. Drainage should be left in place between thirty-six and forty-eight hours. The replacement of drainage will depend on the type of infection. In early cases where there has been prac- tically no necrosis of tissue and gross slough is absent, drainage can be omitted. In cases where necrosis has occurred or is inevitable, drainage should be replaced, but with the greatest care, so as to hold open the wall of the sinus but not to press in any way upon the tendon or its sheath. The accurate placement of drainage and its rapid removal are most to be desired. In short, the governing principle should be to establish drainage so as not only to give an exit for exudate but to preserve — and this is most important — the blood supply and nutrition of the tendon and its sheath. The incisions for drainage of the radial and ulnar bursse are shown on the diagram (Fig. 112), and care in draining the radial bursa in the palm should be taken not to cut the median nerve branches to the outer thenar muscles that cross the line of incision at the lower margin of the annular ligament. These can readily be seen. Should an adherent flexor longus pollicis tendon result in a stiff thumb the functional result, though not perfect, is good. Should the external thenar muscles be paralyzed, adduction will 15 226 INJURIES AND DISEASES OF THE SKIN occur to a greater or less extent, and the functional result be unneces- sarily impaired. As regards the incision of the annular ligament in severe cases, it has been done repeatedly without serious results. On the other hand, just as in the phalangeal annular ligaments, a few strands of its proximal portion may well be left intact to prevent subsequent tendon prolapse without interfering with drainage. Should there be an extension from the radial and ulnar brusae to the potential space in front of the pronator quadratus muscle, the incision should be on the side of the forearm, as already indicated. The whole hand should be placed in a comfortable position on a splint outside of a sterile towel that has been wrapped round the dressing. Measures should be taken to prevent « #• Fig. 114. — Photograph of the thenar swelling in an early abscess of the thenar space. The line of incision for drainage of the thenar space, or the space between the adductor transversus and first dorsal interosseous, is also shown. retention of exudate due to clotting along the drain or at the skin surface. Normal salt solution of a temperature of 106° F. should be dripped on the dressings inside the sterile towel for twenty minutes or thereabouts every two or three hours. These drips can be main- tained for the first day or two and their intervals lengthened as may seem wise. They give great relief to the patient. The external dressing should be changed after twenty-four hours and if the drains are adherent they should be gently loosened at the surface. After the moist drips have been discontinued, baking of the whole part in a dry dressing two or three times a day for three-quarters of an hour with dry hot air at a temperature between 300°-400° F. is recom- mended. The greatest care in all dressings should be taken to avoid DISEASES OF THE SKIN 227 hemorrhage or pain. Both probably indicate unnecessary insult to the tissues. After the acute inflammatory symptoms have dis- appeared active motion can be recommended, but passive motion only in most intelligent hands and never so as to cause pain. Treatment of Thenar and Mid-palmar Space Infections. — The mid- palmar space should be drained as indicated in the diagram by incisions Fig. 115. — Drawing from Kanavel showing methods of draining the mid-palmar space along the lumbrical canals of the little or ring fingers, and the thenar space in the web between the thumb and index finger, just in front of the adductor transversus muscle. Observe that in this manner drainage is between or behind the tendons. between the fingers along the lumbrical canals, avoiding any trauma to the tendons. The incision for draining the thenar space is through the web between the thumb and index finger where the free edge of the adductor transversus muscle is readily exposed (Fig. 114). The thenar space can then be entered just anterior to it and the space between the adductor transversus and the first dorsal interosseous can be entered directly posterior to it (Fig. 115). 228 INJURIES AND DISEASES OF THE SKIN Erysipeloid Infection of the Hand. — This type of infection is seen chiefly in fishmen and cooks. It is due to a rod-shaped bacillus described by Rosenbach. It is a cellulitis and dermatitis. It rarely forms pus. It rarely extends above the wrist, or to it. It causes considerable swelling, only slight tenderness, marked redness resemb- ling erysipelas in its well-defined border, but without its constitutional symptoms. The tissues are tense but limitation of motion is slight. It is often unrecognized and operated on unnecessarily. Its treatment is immobilization and dressing, preferably with 20 per cent, ichthyol ointment. Recovery often takes from ten days to two weeks. Clavus, or Corn. — Corns are conical epidermal hypertrophies occurring on the feet, at points pressed upon by ill-fitting shoes. When situated on the dorsal or plantar surface of a toe they are dry and hard; when between the toes they are softened by the perspiration. Both varieties are painful and at times disabling. Treatment. — The prophylactic treatment consists in wearing hygienic shoes which are so constructed as to avoid undue pressure at any point. Corns may be removed by daily touching them with a mixture of salicylic acid and collodion, 60 grains to the ounce, and afterward peeling off the collodion cap with as much of the softened callus as will easily come away. Removal with the knife after soaking in hot water is quicker, and if skilfully done can be accomplished without bleeding or wounding the healthy skin. Soft corns should be treated with aristol or some other drying powder applied on cotton or gauze placed between the toes to absorb the moisture. Rare Forms of Chronic Infection of the Skin. — Actinomycosis, blastomycosis, and syphilis exhibit a variety of cutaneous lesions. The diseases are described in Chapter IV, but for a description of the skin lesions the reader is referred to some treatise on dermatology. Mycetoma. — Mycetoma, or Madura foot, is a chronic infection begin- ning in the skin of the foot, characterized by the formation of extensive granulomatous areas which slowly destroy all of the tissues of the foot and necessitate amputation of the limb. It prevails in India and other tropical countries, but is rarely seen in the United States. Frambesia. — Frambesia or yaws is another tropical disease of the skin characterized by the formation of papular lesions chiefly in regions where skin and mucous membrane join. The lesions are more or less confluent, exhibit a purulent discharge, are often covered with crusts, and finally develop into a raw fungating bleeding ulcer, which occasion- ally heals spontaneously. Surgical removal by means of the cautery or curette is the treatment to be recommended. Guinea-worm. — This disease is characterized by the formation of an oval vesicular lesion of the skin, which is caused by the presence of the Filaria medinensis, a long, slender worm. The disease is acquired in the tropics, and in all probability through drinking-water. The embryos are taken into the alimentary canal, migrate to the skin and develop just beneath it, where they lie coiled up, and by their DISEASES OF THE SKIN 229 presence give rise to sufficient local irritation to produce the vesicle. When the lesion is fully developed the worm occasionally can be felt through the epidermis. The lesion may be removed surgically or the worm killed by antiseptic injections. Ainhum. — Spontaneous amputation of the finger or toe by the formation of a cicatricial ring or keloid formation which slowly progresses and eventually cuts off the blood supply to the digit. It occurs chiefly in negroes who inhabit tropical countries, and affects by preference the fifth toe. Ulcer. — An ulcer is a raw surface caused by a more or less extensive necrosis of the skin or mucous membrane. On mucous surfaces any loss of substance is spoken of as an ulcer. In the skin, necrosis or destruction of the epithelial layer only is called an abrasion or excoria- tion, the term ulcer being applied only when the destructive process has extended into the corium or below it. Ulcers not infrequently involve the subcutaneous cellular tissues, muscular and fascial layers. An ulcer may be caused by a destructive process which begins on the surface and progresses inward, as an ulcer from a burn or one resulting from a superficial trauma; or it may begin within or beneath the skin and work outward, as an abscess, or gumma, which gradually extends until the superficial layers are invaded and destroyed. An ulcer may be caused by trauma, by the action of chemical or thermal irritants, by inflammatory processes, by pressure, by interfer- ence with the circulation of a part, by disease or interference with the trophic centres or nerve fibres, by the sloughing of new growths or one of the infective granulomata, and by the inability to close completely large cutaneous or mucous membrane wounds occurring in surgical operations. With the exception of aseptic surgical wounds, practically all ulcers are infected with pyogenic bacteria. Most ulcers begin by an area of necrosis, which may be located superficially or below r the surface. This area may be extensive, as one caused by a burn or a severe trauma; or it may be small, such as is seen often in the minute central slough of a syphilitic lesion of the skin. Around this necrotic area there will occur a zone of hyperemia, and later a round-cell infiltration of the tissues. As a result of this inflammatory process the slough is gradually separated and may be cast off en masse or liquefy and be discharged as pus. If the original cause of the necrosis is a progressive one, it may extend peripherally and slough centrally, causing a gradually increasing ulcer, as seen in the serpiginous syphilides, rodent ulcer, or the ulcers of tuberculosis. When the progress of an ulcer ceases and all sloughs are cast off, granulations appear on its base, which grow rapidly and eventually fill the cavity. The granulation tissue, at first soft and vascular, gradually becomes converted into connective tissue, the fibres of which contract and tend to draw the edges together. Cicatrization occurs from the growth inward of epithelium from the cutaneous margins. The clinical appearances and general behavior of the various forms 230 INJURIES AND DISEASES OF THE SKIN of ulcer differ greatly, and have led to a number of rather elaborate and unsatisfactory classifications. Perhaps the most satisfactory classification would be that based upon their etiology. We would then have six general classes— those due to trauma, to infections, to circulatory changes, to trophic dis- turbances, to constitutional diseases, and to new growths. The traumatic ulcers would include those due to loss of tissue from injury, from chemical or thermal agents, from electric currents, or the z-rays. The infective ulcers would comprise those due to acute or chronic infections of the skin or mucous membrane, as ulcers resulting from furuncles, carbuncles, cellulitis, syphilis, tuberculosis, actinomycosis, blastomycosis, and many other acute or chronic inflammatory processes. The circulatory would include those due to a diminished blood supply, as from arterial sclerosis, thrombosis or embolism, pressure ischemia, and those due to an impeded venous current from cardiac disease or varicose veins. The trophic uh-rrs are those due to imperfect nutrition from loss of nerve supply to a part or from some central nervous lesion. Nerve section or neuritis, locomotor ataxia, and syringomyelia are the commonest etiologic factors in this class. Of the constitutional diseases which give rise to ulcer may be men- tioned scurvy, diabetes, the various forms of nephritis, typhoid fever, and other debilitating conditions. The ulcers due to new growth are the epithelioma and the secondary ulcers due to necrosis of deep-seated carcinomata or sarcomata. In all of these classes certain clinical types of ulcer appear, some of which it is well to recognize. Healing Ulcer. — When the process of repair is well under way, practically all ulcers look alike. The loss of substance is replaced by a bright-red mass of granulations, which is covered with a thin layer of healthy pus; the edges of the ulcer are soft and thin, and gradually fade into a bluish film which extends over the marginal granulations. The surrounding skin is soft and healthy. Fungating or Exuberant Ulcer. — The fungating or exuberant ulcer is characterized by an excessive growth of granulations which project well above the surrounding skin, bleed freely, and generally appear pale or flabby. There is little or no tendency to cicatrization. Not infrequently this condition is due to the irritation produced by a foreign body imbedded in the granulations, as a ligature or spicule of bone, or to a persistent discharge from some septic focus. Inflamed Ulcer. — The inflamed ulcer appears red and angry. The base is necrotic, the edges everted and overhanging, the surrounding skin congested and edematous. The entire region is painful and tender to pressure. The cause may be external irritation, impeded venous circulation, constitutional causes, as gout, eczema, etc., or infection. DISEASES OF THE SKIN 231 Indolent or Chronic Ulcer. — Any ulcer may become indolent from neglect, impeded circulation, or constitutional causes. These ulcers may occur in any part of the body, but are most frequently seen on the lower legs of elderly people with varicose veins and edematous tissues. They appear as large unhealthy-looking sores, with thickened purple margins, the central area consisting of an irregular surface of pale flabby granulations, often showing exposed necrotic shreds of fascia, muscle, or bare bone. They have a glazed, dry appearance, and the surrounding skin is thickened, congested, edematous, pigmented, and occasionally the seat of a chronic eczema. Spreading, Phagedenic, or Sloughing Ulcer. — This resembles the inflamed ulcer, but has in addition a tendency to spread rapidly. The base is usually necrptic, the edges greatly undermined, and the sur- rounding tissues deeply congested. There is usually an abundant thin, foul-smelling discharge. The neighboring lymph nodes are enlarged and there may be considerable general sepsis. The cause is usually a virulent infection, a depraved constitutional state from disease or dissipation, or both combined. Scorbutic Ulcer. — This appears most frequently on mucous mem- branes, but it may occur also upon the skin. The cause of the necrosis is usually a blood clot. The destruction of tissue is often rapid and extensive, the base of the ulcer is frequently black or covered with a fibrinous exudate, and there is a marked tendency to bleed on the slightest contact. Syphilitic Ulcer. — A late syphilitic ulcer is practically always a necrosing gumma. The base is usually indurated. The surface is generally covered with a white slough at ■ first, which later becomes of a dirty gray color and gradually separates. Under favorable con- ditions after separation of the slough the ulcer is gradually converted into a healing ulcer, which finally cicatrizes, leaving a depressed scar covered with a thin pearly-white cicatrix which is easily made to wrinkle by pressure on the surrounding skin. Under unfavorable conditions the peripheral induration spreads, the central loss of sub- stance becomes larger and may reach an enormous size. The shape of the ulcer is generally round or oval. Tuberculous Ulcer. — This occurs in several forms. The tuberculous wart, commonly seen in butchers and in those who handle anatomic material, appears usually on the back of the fingers as an indolent induration which finally ulcerates and slowly spreads to the surrounding tissues. The tuberculous gumma occurs as an indolent bluish-red infiltration of the skin, often in the region of tuberculous lymph nodes. The lump finally softens, a superficial slough forms, and the mass is dis- charged, leaving a necrotic undermined ulcer with irregular, corrugated edges surrounded by a purple or bluish infiltration of the skin. Later the cavity fills with unhealthy graulations which secrete a thin, watery pus. There is little tendency to heal. 232 IX JURIES AND DISEASES OF THE SKIN The most destructive form of skin tuberculosis is lupus. While this disease may occur in any part of the body, it attacks by preference the face, generally beginning at the junction of the cheek with the ala of the nose. It is more frequent in women than in men, and occurs, as a rule, in the first or second decade of life. The disease begins by the formation of several small nodules in the corium, which grow slowly, gradually undergo necrosis, and coalesce. As the process first appears on the surface of the skin, there is a small elevated yellow- ish or brownish area surrounded by a number of soft nodules about the size of the head of a pin. This central area soon breaks down, leaving a shallow, indolent ulcer which furnishes a small amount of purulent secretion, in which tubercle bacilli may be found. As the process extends the peripheral nodules slowly undergo necrosis, and new nodules appear in the surrounding skin. Crusts occasionally form on the surface of the lesion, and in some cases pale granulations appear, and eventually result in slow cicatrization of one part of the ulcer as Fig. 110. — Tuberculosis of the skin. it extends in another. While the disease in most instances is limited to the skin and subcutaneous tissue, it may extend to muscle, cartilage, and bone, causing extensive destruction of tissue and great deformity. Marjolin's Ulcer. — This disease is an epitheliomatous degeneration of a chronic ulcer or of irritated scar tissue. It occurs in old and neglected leg ulcers, in the ulcers associated with multiple fistulous openings about the perineum or ischiorectal region, in chronic ulcers from irritation of the tongue or mucous membrane of the cheek, or in any other tissue of the body where a chronic ulcerative process is subjected to constant irritation from any cause. The malig- nant change in all probability arises from the fact that certain young epithelial cells become imbedded in the granulation tissue and form a tumor matrix, which later undergoes more or less rapid proliferation. This change is indicated by a hardening and elevation of the edges of the ulcer, rapid marginal infiltration, a papillomatous appearance PLATE IX Basal Cell Epithelioma of Scalp. (Lumiere Photograph.) Patient in the author's service at the Roosevelt Hospital. DISEASES OF THE SKIN 233 of the surface, a tendency to bleed easily, and the occurrence of an increased amount of pain. Epitheliomatous Ulcer. — This occurs in two forms. The basal-cell epithelioma or rodent ulcer, which appears first as a warty growth, generally on the face. This later ulcerates and slowly spreads as a round superficial ulcer with a smooth, glossy base and slightly elevated, rounded, hard edges. The growth is exceedingly slow, but it never heals. It apparently never involves the lymphatic structures, and if Fig. 117. — Epithelioma of the hand. thoroughly removed never returns. It occurs after middle life, and is painless. The other variety of epitheliomatous ulcer is the ordinary squamous cell epithelioma, which occurs most frequently at the mucous and cutaneous margins. It also is a disease of later life, may occur on skin or mucous membrane, and begins as a warty nodule, an abra- sion, or, rarely, as a crack in the mucous membrane of the lip which shows no tendency to heal. The nodule soon ulcerates and presents hard, irregular margins with an angry, granular base. The growth is at first slow, but later becomes more rapid and is accompanied by 234 INJURIES AND DISEASES OF THE SKIN pain. The lymphatic structures are later involved, and the disease is of a decidedly malignant character. Secondary Malignant Ulcer. — This is formed by the breaking down of carcinomatous and sarcomatous deposits. They extend rapidly, cause extensive destruction of tissue, and constitute one of the most distressing of the terminal symptoms of malignant disease. Treatment of Ulcers. — In the treatment of ulcers the plan to be followed should be, if possible, to convert the various forms of ulcer into the simple healing variety, the treatment of which will be outlined below. In the case of squamous cell epithelioma, or the secondary ulcers of carcinoma and sarcoma, this never can be accomplished, and the only hope of cure is by early and thorough removal of the disease with the adjacent lymphatic structures. In rodent ulcer and lupus complete excision is undoubtedly the best treatment, and many permanent cures are effected by this method. The frequent location of these diseases on the face, however, will often preclude the possibility of such radical measures, and caustic applications preceded by thorough curetting have been followed by success in the case of rodent ulcers, and antiseptic measures occasionally have been successful in lupus. The use of the a>rays, Finsen light, and radium in these conditions has gradually replaced most of the older methods of treatment. For the treatment of rodent ulcer the x-rays or radium is to be recommended, for lupus, the Finsen light therapy. In actinomycosis and blastomy- cosis the internal use of potassium iodide or the copper salts has been found to be of value in combination with local antiseptic applications or the use of radiant energy. Syphilitic ulcers should be treated by mercurial ointment locally, by the administration of salvarsan, and by the internal use of mercury and potassium iodide, the latter to be given in progressively increasing doses. The spreading ulcers, if of septic origin, should be treated with glutol or formalin-gelatin, or thoroughly cauterized with pure nitric or carbolic acid, and afterward treated by a wet carbolic acid or bichloride dressing. Inflamed or varicose ulcers should be kept at rest by placing the patient in bed, and treated at first by hot poultices or a dressing of weak bichloride or carbolic solution until the chronic- passive congestion is relieved, the edges softened and more healthy, and the sloughs separated from the floor of the ulcer. After this, granulation should be stimulated by a wet dressing of myrrh wash (1 part of tincture of myrrh to 12 parts of water), red wash or the use of unguentum hydrargyri, half-strength. In the exuberant ulcer the cause of the overgrowth should be found and removed, after which the granulations should be cut down to the level of the surrounding skin with scissors, and silver nitrate applied. If the granulations are pale and watery, the application for forty-eight hours of several layers of gauze soaked in glycerin will often cause them to shrink from the withdrawal of fluid, and stimulate them to a healthy growth. NEW GROWTHS OF THE SKIN 235 The treatment of a healing nicer should consist chiefly in what Morris speaks of as a " skilful neglect" — that is, avoiding measures which retard repair, such as irritating dressings frequently changed, excessive movement of the part, and positions which favor active or passive congestion. The part should he kept at rest in such a position as to favor free circulation, especially the return of venous blood. Astringent wet dressings, such as myrrh wash, black wash, or alumin- ium acetate, are serviceable; also bland ointments, as cold cream, lanolin, white vaseline, or zinc oxide ointment. Strapping the ulcer and surrounding skin with overlapping strips of lead or zinc oxide plaster and allowing the plaster to remain in place three or four days, or encasing the entire leg and foot, with the exception of the toes, with an evenly applied strapping of plaster often will be followed by rapid healing. In varicose leg ulcers the use of an elastic stocking or Martin's bandage will improve the circulation and favor cicatrization. Protecting the granulations with gold-beater's skin or silver foil is to be recommended. Large ulcers which do not heal rapidly should be subjected to skin-grafting. NEW GROWTHS OF THE SKIN. Papillomata, or Warts. — Warts are cutaneous excrescences and con- sist of a group of hypertrophied papillae covered with epithelium, forming an oval or conical tumor which varies in size from that of a pin's head to that of an orange. They occur chiefly on the hands, on the penis, and about the female genital organs and the anus. Their growth on mucous surfaces is favored by heat, moisture, and the presence of irritating discharges. From cutaneous surfaces they should be removed by thorough curetting and the application of solid silver nitrate to the resulting wound. The application of glacial acetic acid or the use of the x-rays or radium also has been recommended. From mucous surfaces they may be simply removed with scissors, and the wounds dressed with aristol or other antispetic powders. Sebaceous Cysts. — These tumors (Fig. 120) are of fairly frequent occurrence, especially on the scalp. They are encapsulated masses of sebaceous material due to a retention of the secretion of a sebaceous gland. They are round, painless swellings in the skin, and on close inspection a black comedo generally can be seen on the summit of the mass. Treatment. — The treatment should be by incision to the capsule, and by enucleation by a probe or some other blunt instrument. Dermoids. — These cysts occur often in the median line of the body or over the situation of the embryonic clefts. The superficial variety, called atheromatous dermoids, resemble closely the sebaceous cysts in that they contain a semisolid, cheesy material made up of the secre- tion of sebaceous glands and macerated epithelial cells. The deeper 236 INJURIES AND DISEASES OF THE SKIN Fig. 118. — Sebaceous cyst of the scalp. »-Otftf Fig. 119. — Sebaceous cyst of the scalp. NEW GROWTHS OF THE SKIN 237 varieties often contain hair, teeth, and other tissues. They will be described more at length in other sections. Fibromata. — Fibromata of the skin are of fairly frequent occur- rence. The hard fibromata are composed of dense fibrous tissue, which in their growth cause a thickening of the surrounding tissues resembling a capsule. These not infrequently arise from the sheath of a cutaneous nerve, the painful subcutaneous tubercle, and give rise to more or less severe pain. The soft fibromata are made up of areolar tissue and are often pedunculated. These frequently are multiple, develop along the cutaneous nerve trunk, and constitute a condition called fibromata molluscum. Fibroneuromata are tumors growing from a cut or injured nerve, and contain both fibrous tissues and nerve filaments. Moles are fibromata of the skin which are generally congenital, are pigmented, and frequently present a growth of hair on their surface. Fig. 120. — Multiple atheromatous cysts (wens). (Lexer.) These tumors rarely give rise to surgical indications unless they are painful or produce deformity, in which case they should be removed. Care should be taken, however, to remove the entire growth, as par- tial removal, especially in pigmented moles, is occasionally followed by malignant degeneration. Keloid. — Keloid is an exuberant cicatrix caused by the development of an abnormal amount of fibrous tissue in and about the scar of a wound or burn. It appears gradually after the complete healing of the wound, and may continue to enlarge for several months. At first the tissue is highly vascular and has a purplish appearance; later it becomes paler and more firm. It occurs with great frequency in the negro race (Fig. 121). Occasionally these growths undergo sarcomatous change. 238 INJURIES AND DISEASES OF THE SKIN Treatment. — Considerable difference of opinion exists regarding their treatment. Some surgeons advise complete removal with careful union of the wound, hoping for primary union with a small scar. Others advise non-interference, for the reason that the secondary scar is liable to be as large or larger than the one removed, and also for the additional reason that surgical interference occasionally seems to favor the development of malignant changes. The hypodermic use of thiosinamine is said to produce shrinkage in the keloid tissue in certain cases. The .r-rays or radium may be useful. Fig. 121. — Keloid tumors of bark. (Roberts.) Carcinoma. — This occurs as a primary growth in the skin, epithe- lioma; as a secondary involvement from some adjacent organ; as a degenerative process engrafted on some benign skin lesion, as an ulcer, wart, or mole; or, very rarely, as a metastatic deposit, which may be single or multiple. Epithelioma has already been considered earlier in the chapter, and the general features of carcinoma have been discussed in Chapter IV. Sarcoma. — Primary sarcoma of the skin is exceedingly rare; sar- comatous degeneration of a fibroma is more frequently observed. This change occurs commonly in pigmented moles. SKIN-GRAFTING 239 Secondary sarcomatous deposits in the skin are not infrequent. If the primary growth is a melanotic sarcoma, the secondary nodules will contain pigment. Idiopathic multiple hemorrhagic sarcoma has been described, also sarcomatosis cutis. These diseases are characterized by the develop- ment of multiple small sarcomatous lesions over large areas of the body. In the former condition the lesions are dark red or purple in color and may resemble angiomata; in the latter the lesions exhibit no pigment or unusual vascularity. In the treatment of malignant growths of the skin the same principles should be followed as in other tissues. Early radical removal constitutes the best treatment, when the disease can be completely eradicated. In the various secondary and metastatic lesions this plan is abviously impracticable, and palliative measures are to be recommended. The x-rays or radium will often be of service in these cases, and in the sarcomata the use of Coley's fluid is to be advised. Keen has recently emphasized the fact, which is not yet fully appreciated by the profession, that warts and moles when subjected to more or less constant irritation are prone to undergo malignant change, and should be removed before malignant degeneration has occurred. When the irritated lesion is a papilloma, epithelioma is produced; when a mole, either carcinomatous or sarcomatous transformation may occur. When, after a long period of quiescence, one of these lesions begins to grow, malignant change has probably occurred and demands prompt radical treatment. SKIN-GRAFTING. Skin-grafting is employed to hasten the healing of large ulcers and consists in removing portions of epidermis from the inner aspect of the arm or thigh, and planting them on the healthy granulations of an ulcer. The ulcer and surrounding skin, as well as the skin on the part from which the grafts are to be taken, should be rendered aseptic by the usual process. The granulations, if exuberant, are to be curetted to the level of the surrounding skin; hemorrhage should be checked by sponge pressure and hot irrigation with normal salt solution. Reverdin's method consists in cutting small pieces of epidermis from a healthy part by scissors and placing them on the ulcer, the cut surfaces being in contact with the granulations. In Thiersch's method long strips of epidermis are cut with a razor from the inner side of the thigh or arm, and carefully laid upon the ulcer in such a manner as completely to cover it. Considerable skill is required to cut these strips, which should be exceedingly thin, and are best cut while the skin is on the stretch by being drawn upward and downward with the edge of a narrow board, or by McBurney's hooks (Fig. 122). 240 INJURIES AND DISEASES OF THE SKIN When the grafts are in place they are covered with several overlapping strips of rubber protective tissue and surrounded by several thicknesses of sterile gauze wet with normal salt solution, and the whole held in place by a bulky dressing of cotton and a snug bandage. The rubber tissue should, if possible, be left in place for a week or ten days. After a successful grafting the granulations will be covered with a delicate bluish transparent epidermis, which soon spreads over the entire ulcer and gradually thickens. In the subsequent dressings the rubber protective tissue should be used until the grafts appear vigorous, after which any simple sterile dressing will answer. Halsted has suggested the use of silver foil in place of rubber tissue in the primary dressing. Wolfe Grafts. — The use of grafts made by transplanting sections of the entire skin may be necessary in case of marked cicatricial deformity, on account of the fact that in these cases the Thiersch grafts show a Fig. 122. — McBurney's hook. tendency to contraction and produce a recurrence of the deformity. This method was suggested by Wolfe, of Glasgow, who first employed it for the relief of ectropion. It has been extensively employed in other localities, as about joints and over exposed tendons. The cicatricial tissue should first be completely removed and the hemorrhage checked by hot compresses and pressure. An area of healthy skin somewhat larger than the denuded area is next dissected from the thigh or arm and transferred to the original wound. This is held in position by a few sutures, and the wound dressed as after the Thiersch graft. It is desirable to allow the primary dressing to remain in place for from six to ten days, and when dressed to disturb the graft as little as possible, as the early vascular connections are extremely delicate and easily ruptured. This method has not been as successful as the others, and for that reason is rarely used. Dowd has, however, reported a series of cases where he obtained success in over 90 per cent, of his operations. CHAPTER XL THE SURGERY OE THE PERICARDIUM AND HEART. 1 INJURIES OF THE PERICARDIUM. Wounds of the Pericardium. — Wounds of the pericardium are usually complicated, 'although independent injury of the pericardium may occur. Clinically a wound of the pericardium cannot be differ- entiated from one involving the heart. The outcome of these cases depends largely upon the associated injuries and subsequent complica- tions. The operative treatment is discussed under Wounds of the Heart. Foreign Bodies in the Pericardium. — The presence of a foreign body in the pericardium is a very common complication of pericardial wounds, and even more frequent in association with wounds of the heart. Bullets, needles, pins and fragments of weapons are the foreign bodies usually found. A small body, such as a bullet, sometimes becomes encysted in the pericardial sac without interfering with the general health of the patient. When infection is introduced with a foreign body, suppura- tive pericarditis may develop. Plastic pericarditis is a common sequel to pericardial wounds, but complete adhesions rarely follow. The principles of treatment are discussed under Foreign Bodies in the Heart. DISEASES OF THE PERICARDIUM. Inflammatory Exudates. — -The large majority of operations upon the pericardium are undertaken to rid it of fluid contents of inflam- matory origin. Serous Effusions. — It must be emphasized that a serous effusion is usually absorbed, that its presence rarely affects the action of the heart except when it is extremely large in amount, that the impaired heart action is due chiefly to associated myocarditis, that toxic symp- toms due to serous effusions are not marked, and that any prolonged pericarditis may be associated with the formation of extensive intra- pericardial adhesions which frequently produce permanent impairment of the heart action. 1 This revision is largely an abstract of an article by Dr. Pool in Johnson's Operative Therapeusis. 16 242 SURGERY OF PERICARDIUM AND HEART Indications for Treatment. — A serous effusion should be removed as soon as there is evidence that its presence embarrasses the heart. In general the following rules should be followed: Small serous effusions should receive symptomatic treatment; large serous effusions which persist after a brief trial of non-operative measures should be removed. If the fluid reaccumulates rapidly or in large amount, it again should be removed. For tjie removal of serous, serofibrinous, and hemorrhagic exudates, paracentesis is the operation most fre- quently employed, and is the one usually to be recommended. The immediate result of the removal of serous effusions is usually disap- pointing because the embarrassment of the heart action, as a rule, is not due to the presence of the fluid but to an associated myocarditis. Suppurative Pericarditis. — This condition represents an abscess corresponding to a part or the whole of the pericardial sac. The most frequent organisms are the streptococcus, staphylococcus, and pneumococcus. The exudate is usually purulent from the beginning of the attack, although occasionally it develops in the course of a non- suppurative pericarditis. As a rule, purulent pericarditis is secondary in the course of pyogenic infection, and under such conditions it frequently constitutes a "terminal infection;" in rare cases sup- purative pericarditis is primary; in some cases the infection is intro- duced through a wound. Suppurative pericarditis is characterized by the local signs of peri- carditis,with effusion and constitutional symptoms of a septic character. The fact that the pericarditis is frequently a secondary lesion causes its presence to be overlooked in many cases. In children the symp- toms of pericarditis are particularly apt to be masked. On the other hand, in many cases where the lesion has been recognized and the pericardium drained, the operation has been unsuccessful because a coexisting purulent focus, especially empyema, has been overlooked. It follows that in septic processes it is necessary to watch for the development of pericarditis; moreover, the recognition of such a condition should not cause less thoroughness in the search for other foci. Suppurative pericarditis demands immediate incision and drainage. Tuberculous Pericarditis. — Tuberculous pericarditis is usually asso- ciated with other tuberculous lesions, especially of the lungs, pleurae or lymph nodes. The tuberculous nature of the process is suggested by evidence of tuberculosis elsewhere, by bloody fluid on paracentesis, and by appropriate tests of the fluid aspirated. Treatment.— The choice of operative procedure lies between aspira- tion, pericardiotomy and drainage, and pericardiotomy followed by suture without drainage. Suppurative exudates should in general be drained; serous exudates aspirated, or, if this is unsuccessful by reason of incomplete evacuation or rapid recurrence, pericardiotomy with closure should be performed, as in tuberculous peritonitis. OPERATIONS ON THE PERICARDIUM 243 OPERATIONS ON THE PERICARDIUM. Puncture or Aspiration of the Pericardium (Parencentesis Peri- cardii). — Its uses may be summarized as follows: 1. As a diagnostic measure to determine the presence and character of an exudate. 2. As a therapeutic measure: (a) in serous or serofibrinous pericardi- tis, for the relief of the heart when embarrassed by the pressure of the fluid, in cases where the rapid increase of such an exudate acutely threatens the heart and lungs; (6) for the removal of large serous accumulations which resist other therapeutic measures. 3. As an emergency procedure, in compression of the heart by hemorrhage (heart tamponade) when incision of the pericardium must be postponed. Paracentesis, as compared with pericardiotomy, presents two striking disadvantages: (1) it exposes to the danger of accidental injury of the heart, the coronary artery or vein, the pleura and internal mammary artery; (2) the evacuation of the exudate is imperfect. The following sites are especially well adapted for the evacuation of the pericardium: 1. A point slightly internal to the left limit of dulness, in the fifth or sixth intercostal space. 2. A point in the angle formed by the insertion of the seventh left cartilage with the base of the xiphoid process. The choice between the two sites must depend upon the individual indications. The inner site exposes to greater danger of injury to the heart; the outer involves the danger of infection of the pleural cavity. In general in small effusions the chondroxiphoid angle is elected; in large effusions, the outer site. Pericardiotomy, or incision of the pericardium, is indicated for the evacuation of an infectious exudate; for the removal of a foreign body; for exploration in doubtful cases of heart injury. Pericardiotomy for the Evacuation of a Purulent Exudate. — In the treatment of suppurative pericarditis, the method of pericardiotomy to be efficient must provide for satisfactory drainage. Therefore the pericardium should be opened at its lowest point and the opening should ensure ready egress for accumulations in both the right and left spaces of the pericardial sac. Further, the method must be sufficiently simple to be rapidly performed; if necessary, under local anesthesia. Local anesthesia is frequently imperative because the heart is apt to be dilated and insufficient. The two methods most appropriate for drainage in suppurative pericarditis are : 1. Resection of sixth costal cartilage (Kocher). 2. Resection of seventh or sixth and seventh costal cartilages (Rehn). The results of pericardiotomy for purulent pericarditis are neces- 244 SURGERY OF PERICARDIUM AND HEART sarily modified by the gravity of the fundamental disease, but striking cures have followed operation in apparently hopeless cases. The mortality of pericardiotomy for suppurative pericarditis is about 60 per cent. Cardiolysis ; Pericardiolysis ; Pericardial Thoracolysis. — As a result of pericarditis, the pericardial sac may become obliterated to a variable degree by the welding together of its two layers through more or less solid adhesions; moreover, as a result of mediastinitis or pleurisy firm adhesions may be formed between the pericardium and neighboring structures. In consequence of such adhesions the heart action is restricted, and the heart is required to do much extra work in over- coming the resistance. The condition is characterized clinically by a more or less marked systolic retraction of the chest wall over the heart with a proportionate diastolic resiliency. Brauer's operation of "cardiolysis" consists in the removal of the ribs which interfere with the cardiac systole. The rigid bony wall is thus replaced by a soft elastic covering which is easily moved by the heart. A flap is formed on the left side corresponding to the fourth, fifth and sixth cartilages and ribs, the base of the flap lying in the axillary line and the free edge at the sternal margin. The soft parts including skin and muscles are turned back, and the exposed portions of the fourth, fifth and sixth ribs and their costal cartilages are removed. The ultimate results are said to be excellent, but depend upon the degree of myocarditis and secondary changes in other organs. INJURIES OF THE HEART. Foreign Bodies in the Heart. — Foreign bodies may reach the heart: through the walls of the thorax, the most common route; through the bloodvessels; through the respiratory passages; or the digestive tract, very rarely. There are cases in which the point of entrance of the foreign body, or the mechanism of its passage to the heart, cannot be ascertained. Diagnosis. — The diagnosis of a foreign body in the heart and its accurate localization rests essentially upon the radiographic findings, as the clinical picture is in no way pathognomonic. Treatment. — In the surgical treatment of foreign bodies in the heart, the operator must be guided by individual requirements. (1) Imme- diate treatment: In the case of small bodies such as bullets, wads, etc., which have been introduced through gunshot wounds, the im- mediate treatment is that of a wound or a suspected wound of the heart. The recognition and removal of the foreign body is a coinci- dence and not the object of the operation. (2) Late treatment: Foreign bodies which have become lodged in the heart demand opera- tion only if they interfere with the cardiac function. In that case, the heart should be exposed; a body embedded in the wall and readily INJURIES OF THE HEART 245 accessible should he extracted, one in an inaccessible position, as the interior of the heart, must, as a rule, be left. Wounds of the Heart. 1 — Injuries to the heart are most frequently caused by stab or gunshot wounds. The heart wall may be injured in part or the whole of its thickness. Associated lesions are frequently present, especially wounds of the pleurae, lungs, coronary artery or internal mammary artery. Hemorrhage from a heart wound is almost always free. The blood may accumulate in and distend the pericardial sac (hemopericardium), or it may enter the pleural cavity if the pericardial wound is such as to afford free communication between the two cavities. When the blood accumulates within the pericardial sac the heart action becomes impeded by intrapericardial tension to an extent dependent upon the amount and rapidity of the hemorrhage. The flow of blood is retarded and finally stopped; ventricular contraction is impeded and ultimately arrested. This is known as heart tamponade (Rose), which may be defined as gradual impairment and ultimate cessa- tion of the heart action as a result of intrapericardial tension due to hemorrhage into the pericardial sac. Symptoms. — The symptoms of a wound of the heart are dependent upon shock, hemorrhage and associated lesions. Shock is usually marked. Hemorrhage may cause: (1) hemothorax, with symptoms of internal hemorrhage and signs of fluid in the pleural cavity or, (2) hemopericardium, w T ith the objective signs of dilatation of the peri- cardial sac and more or less marked symptoms of heart tamponade, which is evidenced by cyanosis, dyspnea, small, weak, irregular pulse, enlargement of the cardiac dulness with feeble, distant heart sounds. Diagnosis. — The diagnosis is often doubtful. There is no typical clinical picture whereby a wounded heart can always be diagnosed, especially in the first few hours after injury. The classical syndrome, "heart tamponade," due to intrapericardial pressure, is more often absent than present (Borchardt) ; physical signs in the cardiac region, such as abnormal sounds and increased dulness, are frequently incon- clusive; the position and direction of the surface wound are not always convincing; w r hile the suggestive symptoms of internal hemorrhage, hemothorax, hemopneumothorax may originate entirely in thoracic lesions other than a heart injury. Treatment. — Immediate exploration is indicated even when the diagnosis is in doubt and a heart wound is probable but not positive. Operation is the proper procedure for the following reasons: The diagnosis of heart wounds is frequently uncertain, especially soon after the injury; the prognosis becomes progressively poorer with delay; the immediate and late results of operative treatment have been much better than non-operative. E. Hesse (1911) collected 219 cases of cardiorrhaphy with 116 1 The section on Wounds of the Heart is abstracted from an article by Dr. Pool in Annals of Surgery, 1912, lv, 485. 246 SURGERY OF PERICARDIUM AND HEART deaths and 103 recoveries. He points out that this ratio gives a false impression of the percentage of cures, because numerous failures doubtless are not reported. Technic of Operation. — Careful preparation of the field of operation is essential, since many fatal results have been due to sepsis. Light general anesthesia, preferably ether, should be given when there are signs of sensibility. It is important to recognize that in a large proportion of heart wounds the pleura is opened and that an extrapleural cardiorrhaphy is rarely possible. Differential pressure offers marked advantages, chiefly by elimi- nating the immediate and minimizing the later dangers due to pneumo- thorax. Its use expedites the operation by allowing a free transpleural exposure. But prior to the control of bleeding from the heart wound positive pressure should be used with great care because it may increase hemorrhage. A transpleural exposure with long intercostal incision (Wilms) is ordinarily the best because it affords free exposure of the heart, can be applied much more quickly than other procedures, and causes less hemor- rhage. This exposure should be employed when differential pressure is used, when speed is important, or when pneumothorax is present. An effort to do an extrapleural operation is warranted under certain conditions. The indications are: Differential pressure not available, pneumothorax not present, no injury to the pleura such as would render the effort useless. Under these conditions, an osteoplastic flap with pedicle outward should be employed. In some cases in which the diagnosis is in doubt, extrapleural exploratory pericardiotomy may be performed by resection of the sixth costal cartilage as in the primary incision of Kocher's flap operation. «% Atypical procedures are at times indicated. Fine vaselined silk on a curved intestinal needle is the best material for heart suture. The pericardium should be closed with interrupted catgut sutures. Pericardial drainage may be dispensed with in some cases when there is short exposure and little trauma. A drain should enter the pericardium to a slight extent when the nature of the wound renders infection probable. But in doubtful cases it is best to insert a drain down to but not into the pericardial wound, a small part of which should be left unsutured. In this way an exit is provided for the large accumulation of serum which is likely to occur after the opera- tion, and no irritation of the pericardium is caused by the presence of a drain. Pleural drainage is a prophylactic step which is often unnecessary and likely to be harmful. Unless there is a strong probability of infection, it is better to delay drainage until infection has occurred and then to do secondary thoracotomy. INJURIES OF THE HEART 247 Cardiac Massage. — Direct massage has been recommended for arrest of the heart during operation. The aim is to stimulate the heart to renewed activity. It must be begun within five minutes after cessation of the heart beats (Jurasz), and the usual measures for the resuscita- tion of a patient should be employed at the same time as the massage. Injurious sequelae have not been noted after recovery, but frequent failures must be expected. The methods of approaching the heart are as follows: 1. Transthoracic route. This consists in lifting a costochondral flap, opening the pericardium and inserting the hand. 2. Transdiaphragmatic method. A vertical incision is made below the ensiform cartilage, and a second incision through the diaphragm into the pericardium. 3. Subdiaphragmatic method differs from the transdiaphragmatic in that only the abdominal incision is made; the heart is massaged with the hand beneath the flaccid diaphragm. In the transthoracic method the pleura is generally opened, entailing pneumothorax. The transdiaphragmatic method avoids pneumo- thorax, but the method has not shown advantages over the sub- diaphragmatic method. The subdiaphragmatic method, according to most authorities, is the simplest and quickest for making the heart accessible for massage, and affords the best results. Jurasz is in favor of employing this method in all cases in which the abdominal cavity has been already opened. In other cases, it is questionable whether time should be consumed in opening the abdomen. Experimental Surgery of the Heart. 1 — The bad results following intrathoracic operations in experimental as well as clinical surgery are due to a lack of adaptation of the technique to the physiological conditions of the chest. The complications which often kill the animal or the patient are brought about directly or indirectly by the infection of the pleural or pericardiac cavities, or by the respiratory disorders caused by the penetration of the air into the thorax. "The success of the more complex intrathoracic operations depends upon the observance of a number of minute details of technic. It is necessary mainly to remove some of the factors causing irritation of the pleura. "In the more extensive operations, the Meltzer and Auer method of intracheal insufflation should be used. "Theoretically, many operations can be performed on the heart; incision and dilatation of stenosed valves, cuneiform resection and stenosis of the upper part of the ventricle in cases of mitral insufficiency, curettage of endocardiac vegetations, grafting of new vessels on the auricle and ventricle, collateral circulation between two cavities of the heart, aortocoronary anastomosis, etc." Carrel states that the "plastic operations on the heart are not very much more difficult 1 Carrel, Annals of Surgery, 1910, lii, 83. 248 SURGERY OF PERICARDIUM AND HEART than on other parts of the body. But to perform the operations without disturbing in an irreparable manner the functions of the nervous system and of the heart itself is a very complicated prob- lem. The technie of these operations is far from being completely developed." WOUNDS OF THE BLOODVESSELS. (See Hemorrhage, Chapter VI). DISEASES OF THE BLOODVESSELS. Acute Arteritis. — Inflammation of one or more coats of the arteries may be due to a variety of causes. Acute infective arteritis may arise from extension of an infective process from the surrounding tissues to the artery itself, resulting in a round-cell infiltration of the vessel walls, with softening and necrosis, a condition often giving rise to secondary hemorrhage in suppurating wounds; or the process may arise from the interior of the vessel from the deposit of infected thrombi, as seen in pyemic processes, and as the result of ulcerative endocarditis. Chronic Endarteritis. — Chronic endarteritis is a slowly developing inflammatory process beginning in the interior of an artery and extend- ing to the media and adventitia. It occurs in two forms, the athero- matous and the obliterative. Atheromatous. — In the atheromatous variety there is at first a circumscribed round-cell infiltration of the intima and media, which later undergoes fatty degeneration, forming a pultaceous mass which may separate, leaving a loss of substance on the interior of the vessel, called an atheromatous ulcer. This causes a weakening of the vessel- wall at that point, which may later dilate and form an aneurism, or the ulcer may be covered by a calcareous plate. A plate of this kind may subsequently become loosened and be carried away by the blood- current, forming an embolus, or the blood may find its way underneath it and eventually separate the coats of the artery and form a dissecting aneurism. A compensatory thickening of the adventitia often occurs in these cases, preventing the formation of an aneurism. Athero- matous endarteritis occurs chiefly in the aged, and in those who have suffered from syphilis, nephritis, or the abuse of alcohol. It affects chiefly the larger arteries. Obliterative. — In the obliterative form the infiltration of the intima is more uniform, and causes a gradual diminution in the lumen of the vessel with final obliteration. This occurs more commonly in the smaller vessels, and is generally due to syphilis. Fatty Degeneration. — Fatty degeneration of the intima may occur independently of atheroma and occasion a weakening of the vessel. Calcification of the Media. — Calcification of the media occurs in old people, and renders the arteries rigid and narrow. It is most frequently observed in the vessels of the extremities, chiefly at the points of DISEASES OF THE BLOODVESSELS 249 departure of the principal branches. Tt causes impaired nutrition of the parts, often terminating in senile gangrene. Aneurism. An aneurism is a pulsating hollow tumor filled with blood, communicating with the interior of an artery. Two varieties are commonly described: the true or spontaneous aneurism, and the false or traumatic aneurism. A true aneurism is one in which the walls are formed by one or more of the coats of the artery, and is in reality dilatation of the vessel; a false aneurism is one in which the walls are formed by the surrounding perivascular tissues thickened by blood clot and inflammatory exudate, and is due to rupture of the vessel. Causation. — Two factors may be present in the production of a true aneurism; an increase in the blood-pressure and a weakening of the arterial w r all. The. causes which increase blood-pressure are mental or physical strain, the abuse of alcohol, hypertrophy of the heart, and renal disease; those which weaken the arterial wall are trauma, acute arteritis, atheroma, gummatous infiltration, or obliterating endarteritis of the vasa vasorum. Thus, true aneurisms occur most frequently between forty and sixty, the period of life when physical and mental strain are apt to be greatest, while the heart action is still vigorous, and when degenerative changes begin to occur. For obvious reasons they are more frequent in men than in women. Syphilis undoubt- edly is the most important etiologic factor, the Wassermann reaction being positive in about 90 per cent, of the cases. Development and Varieties of Aneurism. — As a result of increased blood-pressure a portion of one of the larger arteries which has become weakened by atheromatous changes or from any other cause shows a tendency to dilate. The dilatation slowly progresses at first, and may involve the entire vessel, giving rise to a spindle-shaped swelling or fusiform aneurism (Fig. 123). If only one portion of the arterial wall gives way, a pouch-like protrusion occurs, forming a sacculated aneu- rism (Fig. 124). If an atheromatous ulcer forms or if the intima is eroded by the separation of a calcareous plate, the blood dissects its way between the arterial coats and forms a dissecting aneurism (Fig. 125), the cavity of which many communicate with the lumen of the artery at one or two points. Aneurisms occasionally result from the plugging of small terminal arteries by emboli. The dilatation and elongation of an artery or of several arterial branches forming a pulsat- ing mass is spoken of as a cirsoid aneurism (Fig. 126). Minute miliary aneurisms occasionally form on the arterioles, especially in the pia mater, and by their rupture give rise to apoplexy. False or traumatic aneurism is generally the result of a wound of an artery or of rupture of a true aneurism. If as a result of an injury, as a stab or gunshot wound, an arterial trunk is injured, blood is poured out, and a hematoma forms around the vessel. If the resist- ance of the surrounding tissues is such as to prevent a wide diffusion of the extravasated blood, the peripheral portion coagulates, forming a kind of sac which is later strengthened by an inflammatory exudate. 250 SURGERY OF PERICARDIUM AND HEART If the wound in the vessel is not occluded by a clot, fluid blood from the artery is continually pumped into the hollow centre of the mass, Fig. 123.— Fusiform aneurism. Fig. 124.— Sacculated aneurism. Fig. 125. — Dissecting aneurism. forming a gradually increasing pulsating tumor. If the injury wounds not only an artery but also a neighboring vein, the blood may pass from the artery directly into the vein, forming an arteriovenous aneu- rism. Two varieties of arteriovenous aneurism exist: one, in which Fig. 126. — Cirsoid aneurism. (Burns.) the union between the injured vessels is close, called an aneurismal varix (Fig. 127) ; the other, in which the blood passes from the artery X h < a. < DISEASES OF THE BLOODVESSELS 251 into a false aneurism and then into the vein, which is separated from the artery by the aneurismal sac, called a varicose aneurism (Fig. 128). In all aneurisms there is a tendency to gradual increase in size. In true aneurisms the intima and media frequently become atrophied, while the adventitia thickens and occasionally makes up the entire wall of the tumor. As the aneurism enlarges a deposit of fibrin takes place on the interior of the sac, giving rise to great thickening of the walls. This deposit is laminated, and in rare cases develops to such an extent as finally to occlude the vessel and result in spontaneous cure. Spontaneous cure is also rarely effected by a blood-clot or the separation of a mass of fibrin from the walls of the sac, which plugs the outlet or the vessel beyond the tumor. Spontaneous cure may also take place in false aneurisms and in the arteriovenous varieties. Fig. 127. — Aneurismal varix. Fig. 128. — Varicose aneurism. The growth of an aneurism will cause great destruction of neigh- boring tissues. The more resisting tissues, as bone and cartilage, suffer more, as a rule, than the softer and more yielding structures. Thoracic aneurism not infrequently causes erosion of the spinal column and pressure on the cord, as well as bulging and atrophy of the sternum and ribs. Rupture of an aneurism may occur, and suppuration has been observed, generally the result of infection of a wound from distal or proximal ligature. Diagnosis. — The early symptoms complained of by patients suffering from aneurism are usually only a swelling and a disagreeable sense of throbbing over the region of an arterial trunk. Later, as the tumor enlarges, there may be more or less pain, and if the aneurism presses upon and erodes bone, the pain may be very severe. On examination 252 SURGERY OF PERICARDIUM AND HEART a tumor is found which pulsates synchronously with the heart. The tumor is, as a rule, oval, elastic, and gives one the feeling that it contains moving fluid. If the interior of the tumor is largely filled with fibrin, pulsation may be faint and palpation may give the impres- sion of a solid mass. As a rule, the tumor expands in every direction with each heart systole, and if grasped between the fingers or hands in any diameter expansile pulsation will be felt. Aneurisms, as a rule, are compressible. If steady pressure is made with the hand over the tumor, the size will be markedly diminished, and when the pressure is removed it will take several beats of the heart to regain its previous dimensions. Pressure over the main arterial trunk, between the tumor and the heart, will cause the pulsations to cease and the tumor to shrink, while pressure over the efferent portion of the artery will cause it to increase in size. The pulse in the arteries beyond the aneurism will be weaker and the beat somewhat retarded if comparison is made with a corresponding artery on the other side of the body. If the tumor is examined by the ear or stethoscope, a blowing sound often will be heard synchronous with the pulse, which is transmitted in the direction of the vessel. This aneurismal bruit is loudest in the fusiform variety and may be absent in some saculated aneurisms. As the aneurism increases in size pressure symptoms generally arise, such as neuralgic pains, sensory and motor paralysis from pressure on nerves, venous congestion and edema from pressure on veins, various visceral dis- turbances from pressure on organs, as dyspnea and aphonia from pressure or erosion of the larynx or trachea, dysphagia from the pressure of a thoracic aneurism on the esophagus, cerebral symptoms from the pressure of an intracranial tumor. It is often difficult to distinguish between false and true aneurisms. Fake aneurisms are rarely fusiform, and are often somewhat irregular in outline. Pulsation may be absent, or it may be much more distinct in one portion of the tumor than in another. The bruit is rarely as well marked as in true aneurisms. In arteriovenous aneurisms there is usually marked dilatation of the veins in the neighborhood of the injury, and an exceedingly loud, harsh bruit can be heard over the entire region, which, if situated near the head, is extremely distressing to the patient. The dilated, tor- tuous veins may form a large pulsating mass, easily compressible and imparting a distinct thrill to the hand when palpated (Plate X). Cirsoid aneurism may appear as a single tortuous pulsating arterial trunk frequently seen on the scalp, producing no symptoms; it may consist of several dilated arteries, forming a pulsating mass; or the vascular dilatation may extend to the capillaries and venules. In these conditions a tumor is present which is somewhat irregular in outline, may be bluish in color, is pulsating, compressible, and presents a loud bruit on auscultation. Dilated vessels often can be seen running into the mass. This condition is often spoken of as pulsating angioma. Rupture of an aneurism externally produces generally a rapidly DISEASES OF THE BLOODVESSELS 253 fatal hemorrhage; rupture into one of the body cavities produces localized pain and the symptoms of concealed hemorrhage; shock, pallor, cold perspiration, rapid and feeble pulse, air hunger, and syncope; rupture of an aneurism into the solid tissues of a part produces severe lancinating pain, sudden disappearance of the original tumor, and the appearance of a diffuse swelling in the neighboring tissues, with coldness and edema of the parts supplied by the artery and an absence of the pulse in the distal branches. Suppuration of an aneurism is indicated by the local and general signs of inflammation. Treatment. — In the treatment of aneurisms an effort should be made to favor nature's method of cure, which is by the formation of a firm fibrinous occluding mass within the sac. This may be accomplished by lowering the blood-pressure and by diminishing the amount of blood which flows through the sac. Failing in this the disease may be cured by entirely cutting off the circulation through the diseased artery with or without extirpation of the tumor. Non-operative Methods. — Absolute rest in bed combined with an exceedingly low diet, consisting of 2 or 3 ounces of meat, 6 ounces of bread, and 6 ounces of milk or water each day; and the use of aconite and potassium iodide, will undoubtedly produce a marked lowering of the blood-pressure and a diminution in the force and frequency of the heart beat. This treatment should be continued for several weeks or months, and during this period the patient should be kept free from any mental or emotional excitement. The wearing of a moulded lead plate weighing two or three pounds, made accurately to fit the tumor, if practicable, will often prove of great value when combined with rest and low diet. In aneurisms of the extremities moderate pressure over the tumor may be maintained by the use of a rubber bandage. This with elevation of the limb occasionally will succeed in arresting or curing the disease. Treatment by proximal arterial pressure has long been favorably considered by the profession, and many cases have been cured by it. It is, however, applicable to only a limited number of cases. The plan is to cause constant pressure upon the artery at some distance above the tumor. The pressure should, if possible, be such as to include the artery but not the vein, and to produce noticeable cessation of pulsation in the tumor. If the circulation through the sac is entirely cut off, the cavity will rapidly fill with an ordinary red clot of blood. If a small amount of blood is allowed to flow through the aneurism, a firm, white, fibrinous clot will form more slowly, but will be much more likely to remain and produce permanent occlusion of the cavity when the pressure over the artery is relaxed. The methods of arterial compression are two, the digital and the instrumented. The digital is in every way superior to the instrumental, on account of its accuracy, the ease with which it is regulated, and the fact that the vein generally can be avoided and injury of the tissue 254 SURGERY OF PERICARDIUM AND HEART prevented. Relays of assistants are necessary, and when changing, the pressure of the relieved assistant should not be relaxed until the thumb of the relieving assistant is in place. The mechanical means of arterial compression are by the use of the Petit tourniquet (Fig. 129). Two of these should be kept in place, and the pressure point changed every few hours. The use of mechanical apparatus for this purpose is extremely painful, and often requires general anesthesia. During the progress of this treatment the pressure should from time to time be gradually relaxed to determine the condition of the tumor. When, after relaxing the compression, pulsation is found to be absent, the outlook is favorable. The pressure should, however, be continued to a moderate degree for from twenty-four to forty-eight hours more. Violent massage or manipulation of the tumor, with a view to dislodging a portion of the laminated fibrin to cause a plugging of the outlet, is to be condemned as a dangerous procedure. Fig. 129. — Petit's tourniquet. Forcible flexion of the knee or elbow for the cure of small aneurisms situated in these regions has been successful in a number of instances. The effect of the flexion is to occlude the vessel and to produce direct compression on the aneurism, causing rapid clotting of the contained blood. If the limb is held in a position of extreme flexion, the blood current is entirely arrested. If the flexion is of moderate extent, the blood current may only be retarded, favoring the formation of a firm, fibrinous mass within the sac. It is desirable to bandage the limb below the tumor, and after flexion to maintain the position by means of straps, bandages, or an elastic apparatus. Every few hours the flexion should be temporarily relaxed to determine the condition of the tumor. This method should never be employed in large or thin-walled aneurisms, for fear of rupture. Operative Methods. — Complete extirpation of the aneurism with ligature of all the branches and closure of the wound, with a view to obtaining primary union, is the method of choice when it can be safely carried out. It is applicable to all accessible small aneurisms, DISEASES OF THE BLOODVESSELS 255 and in many of the larger ones which can be freely exposed. The chief difficulty experienced in carrying out this plan is in separating the tumor from the neighboring structures, to which it is generally attached by firm adhesions. Extirpation of a portion of the main venous trunk is often necessary on this account, but its removal is rarely attended with serious symptoms, as the pressure of the tumor has, as a rule, already caused the venous circulation to be carried on by other channels. If large nerve-trunks or other important structures are in clanger of being injured, a portion of the sac may be left. The method is to expose the tumor by a long incision which extends above and below sufficiently to give a good exposure of the vessels. Fig. 130.— Double ligature. Fig. 131. — Proximal liga- ture. (Anel.) Fig. 132. — Proximal liga- ture. (Hunter.) The artery above and below the tumor should be double ligated and cut (Fig. 130). The aneurism is then dissected from its bed and other branches, if found, doubly ligated, and divided. Considerable bleeding may occur from the separated adhesions, which should be controlled by ligature, hot water, or hydrogen peroxide, after which the wound should be closed and a dressing applied. In the extremities a splint or stiff bandage should be used to insure absolute rest of the part. In large or thin-walled aneurisms it is often desirable to perform the operation in two stages: first, ligation of the main artery above the aneurism to produce clotting within the sac and diminution in the size of the tumor, and at a later period to remove the sac. This method is undoubtedly safer than to perform the operation while 256 SURGERY OF PERICARDIUM AND HEART the tumor is tense and liable to rupture, and when all the connecting arterial branches are open and pulsating. Proximal ligature is perhaps the method most generally employed at the present time for the cure of aneurisms. Ligature just above the tumor with a view to cutting off the circulation entirely, the method of Anel (Fig. 131), is often employed; but when possible ligature at some distance above the tumor (Fig. 132), the method of Hunter, is to be preferred, as in this operation the circulation is rarely completely arrested and the danger of immediate gangrene is less. Moreover, the artery at this distance above the aneurism is less likely to be diseased and secondary hemorrhage is thereby avoided. The effect of proximal ligature upon an aneurism is the same as compression of the artery; the blood current is either completely arrested or the flow very much diminished. In the former instance a red clot forms at once in the sac, in the latter a laminated fibrinous clot forms slowly and eventually fills the cavity. In either case pulsation ceases in the tumor; it becomes firmer and gradually diminishes in size. Halsted has recently advocated partial obliteration of the lumen of the vessel by means of flat metal bands, which often can be removed at a later period. The nutrition of the parts supplied by the artery will depend upon the possibilities of the collateral circulation and the degree to which the anastomosing vessels have been dilated by the obstruction caused by the aneurism. Generally the pulse below the tumor is immediately obliterated, the parts become anemic and cool, and sensation may be impaired. The circulation, however, is gradually restored, the parts become warmer, and the capillary circulation more active, as evidenced by a more rapid return of the normal pink color of the nail or extremity of the finger or toe after pressure, and a feeble pulsation can be felt in the distal branches. When the collateral circulation is insufficient, the part remains cold and lifeless, and gangrene, generally of the moist variety, develops. Distal Ligature. — Proximal ligature is often impossible on account of the situation of the aneurism or its nearness to an important trunk. In these instances distal ligature is resorted to with a view to arresting the circulation and forming a clot within the sac. The method is inferior to the proximal ligature, and should only be employed when proximal ligature is impossible. Two methods are in use: ligature of the main trunk beyond the tumor, and ligature of one or more branches issuing from the main trunk. The former is known as the method of Brasdor (Fig. 133); the latter, as that of Wardrop (Fig. 134). After any operation in which the main arterial trunk of an extremity is ligated, the limb should be wrapped in cotton batting and bandaged without pressure, external heat applied, and the limb elevated to favor return venous circulation. If gangrene appears, amputation should be resorted to, generally above the point of ligature. The most recent method of treating aneurisms, and on the whole, DISEASES OF THE BLOODVESSELS 257 Fig. 133.— Distal ligature. (Brasdor.) Fig. 134. — Distal ligature. (Warclrop.) Fig. 135. — Shows the orifices in the aneurismal sac in process of obliteration by suture. The first plane of sutures may be made with fine silk, but chromicized catgut is preferable. The sutures are applied very much like Lembert sutures in intestinal work; the first plane of sutures should be sufficient to secure complete hemostasis. The orifice of the collateral vessel on the left upper side of the sac is shown closed by three continuous sutures. 17 258 SURGERY OF PERICARDIUM AND HEART perhaps the best and safest, is that suggested by Matas, in 1888, to which he applied the term endo-aneurismorrhaphy. Recognizing the ready adhesion of sutured serous surfaces, he advises, after compression of the main supplying arterial trunk, incision into the aneurismal tumor, removal of the clots and fibrin, and closure of the arterial orifices by sutures so placed as to insure broad approximation of the margins of the openings (Fig. 135). In sacculated aneurisms he closes the single orifice of communication between the artery and aneurismal sac and thus restores the main vessel (Fig. 136). In certain fusiform aneurisms he constructs a new channel by suturing the walls Fig. 136. — Shows the sac of a sacculated aneurism opened. The dotted lines indi- cate the position and relations of the main artery to the sac and to the orifice of com- munication. The object of the operation in this case is to close the orifice of communi- cation without obliterating the main artery. The closure of the orifice with continued suture is shown in the figure. of the sac over a rubber catheter, in the same manner as the Witzel method of gastrostomy is carried out, removing the catheter, however, before the last suture is tied (Fig. 137). After all of these procedures he obliterates the remaining portion of the aneurismal cavity by closely approximating its walls by suture. After this is accomplished, the wound is tightly closed and an aseptic dressing applied. He claims that this method is safer than the older procedures, the wounds heal more promptly, and in some instances the artery is restored to its original dimensions. Recently Matas has reported a series of 110 cases thus treated with a mortality of only 1.8 per cent, and 3.6 per cent, of subsequent gangrene. DISEASES OF THE BLOODVESSELS 259 Other methods of treatment looking to the formation of a clot or fibrinous deposit within the sac of an aneurism have been suggested from time to time and practised with varying degrees of success. Acupuncture. — Introducing a number of needles into the sac of an aneurism and allowing them to remain ten or twelve hours has occasionally been followed by the formation of firm coagulation within the sac, and cures have been reported. The introduction of large masses of silver, gold, platinum, or steel wire into an aneurism through a minute canula has been successfully employed in a number of cases. Fig. 137. — Shows method of creating a new channel in a fusiform aneurism. The sutures are nearly all tied, and the new channel is completed except in the centre. The two upper sutures are hooked and pulled out of the way while still in position, and the catheter withdrawn. Galvanopuncture, by introducing two fine insulated steel needles into an aneurismal sac and allowing a galvanic current from ten to twelve cells to pass through the contained blood, will often cause the rapid formation of a firm fibrinous mass. A combination of these two last methods has of late been quite extensively employed. Willard has recently reported 24 cases treated in this manner, 10 of which were positively benefited, and all were apparently rendered more comfortable by the treatment. The method consists in introducing- through a fine insulated canula from 15 to 20 feet of fine silver or gold wire previously wound upon a spool to insure 260 SURGERY OF PERICARDIUM AND HEART its curling up within the sac, and to pass through this for one hour a current of from 5 to SO milliamperes, the positive pole being connected with the wire, the negative applied by means of a sponge to the back of the patient. INJURIES AND DISEASES OF THE VEINS. Injuries of the veins and their treatment have been considered under Hemorrhage, in Chapter VII. Phlebitis. — Phlebitis is an inflammation of one or more coats of a vein. Two varieties are described, the plastic or non-suppurative, and the infective or suppurative variety. Plastic phlebitis is said to result from trauma, gout, rheumatism, and other debilitating consti- tutional conditions. It is probably due in the majority of cases to the action of pathogenic micro-organisms, the virulence of which is not sufficient to excite the ordinary evidences of inflammation. The intima of the vein becomes thickened or eroded, a thrombus forms at the site of the lesion which eventually fills the lumen of the vein and many extend upward or downward for a considerable distance. This condition of thrombosis, when it occurs in a large venous trunk, greatly interferes with the return venous circulation and gives rise to edema of the extremity or part below the lesion. The thrombus may become organized and converted into firm connective tissue which permanently plugs the vessel; it may become calcified (phlebolith) ; or it may become canalized by the dilatation of the new capillaries formed within the organized thrombus or a coalescence of small spaces or vacuoles which form during contraction of the clot. If the lumen is restored, the circulation goes on as before; if it is permanently occluded, the free venous anastomosis soon forms compensatory channels. Infective or Suppurative Phlebitis. — This practically always results from some acute inflammatory process in the neighborhood of the vein, generally a cellulitis or infected wound. The process may begin from without and involve all the coats of the vein, or from within by infection conveyed through the blood. There is usually a marked round-cell infiltration of the entire vein. A thrombus forms as in plastic phlebitis, but soon breaks down, forming a purulent mass, which may give rise to local abscesses along the course of the vein, or infective thrombi which are carried to various parts of the body and by their lodgement give rise to secondary suppurative lesions (pyemia). Diagnosis. — The symptoms of plastic phlebitis are simply a thicken- ing of the vein and a certain amount of edema below the lesion. If the vein is a small one and anastomosis is free, edema may be wanting. If the vein is a large one, as the femoral, edema may be marked, increas- ing the circumference of the limb to double its normal size. This continues for from two to six weeks and then gradually subsides. There is, as a rule, no pain, only a feeling of numbness and weight. INJURIES AND DISEASES OF THE VEINS 261 Fever may be present, but is usually of moderate degree. In the suppurative variety the vein and perivascular tissues become thick- ened, hot and tender, the overlying skin reddened and edematous. Fever is present, often accompanied by chills and sweats. If a large trunk is involved, edema may occur as in the plastic variety. Later, suppuration occurs in several places along the vein, or the symptoms of general sepsis with metastatic abscesses develop. Treatment. — In the plastic variety with thrombosis of a large trunk and edema, absolute rest in bed should be advised, with slight elevation of the limb to favor return venous circulation and the application of a moderate degree of heat by means of well-protected hot-water bags. Active movements of the extremity, massage, or any handling of the region of the thrombosed vein, should be avoided on account of the danger of dislodging a portion of the clot. In the infected variety wet dressings should be applied to the infected region and the abscesses opened and freely drained. It is often advisable in the early stages of a septic phlebitis to ligate the vein above and below the thrombus, open and remove the infected mass. If this can be carried out early, metastasis and general sepsis often may be avoided. Varicose Veins. — A permanently dilated, lengthened, and thickened condition of the veins occurs in various parts of the body, and con- stitutes the condition knowm as varicose veins. The predisposing cause of this pathologic dilatation and enlargement is either increased blood-pressure or diminished resistance of the tissues of the vein, or both combined. The exciting cause is generally some extra muscu- lar strain frequently repeated, or an obstruction in the larger trunks, as from thrombosis, the pressure of tumors, or in the case of the low r er extremity, the weight of the pregnant uterus, or the constriction of elastic garters, especially when worn below r the knee. Another, and in the writer's opinion the most important etiologic factor in varicose veins of the leg, is the habit necessitated by certain occupations of constant standing without the opportunity of muscular exercise. The usual situations in which varicose veins are found are the lower extremities, especially below the knees, the mucous membrane of the anus and lower portion of the rectum (hemorrhoids), and in the tissues of the scrotum (varicocele) . Varicose Veins of the Leg. — A dilated and thickened condition of the subcutaneous veins of the lower leg is of common occurrence, chiefly in middle-aged individuals whose occupations require constant standing. The dilated veins are found, as a rule, to be the tributaries of the internal saphenous vein, which may also partake of the process (Fig. 138). Exceptionally the disease affects the external saphenous and its branches (Fig. 139). In the former instance the veins are chiefly on the inner aspect of the calf, while in the latter they are found on the outer side and posteriorly. All three coats of the vein are thickened. The walls are rigid and often calcified. When cut, the vessel remains open like an artery. 262 SURGERY OF PERICARDIUM AND HEART The venous system in the leg consists of two portions, a deep and superficial set of veins. The deep veins collect the blood from the muscles and empty into the anterior and posterior tibials, the peroneal, popliteal, and femoral trunks. The superficial veins form a network of vessels in the subcutaneous tissues, have a number of direct con- nections with the deep system, and eventually empty into the external or internal saphenous vein, the former joining the popliteal at the back of the knee, the latter the femoral at the saphenous opening. During rest most of the blood^from the musculature of the lower extremity Fig. 138. — Varicose veins of leg; internal saphenous branches. passes through the deep veins into the femoral. During violent muscular exertion a large part of the blood from the muscles passes through the unimpeded vessels of the superficial set, which can be seen to dilate during the muscular effort. The superficial veins therefore act as a compensatory system, capable at any time of carrying most, if not all, of the blood returning from the lower extremity. Raymond Russ, who has recently published some interesting studies upon the subject, 1 calls attention to the fact 1 Surgery, Gynecology and Obstetrics, April, 1908. INJURIES AND DISEASES OF THE VEINS 2G3 that, while the exact situation of the communicating branches between the deep and superficial systems may vary in different individuals, in general a free anastomosis exists about the dorsum of the foot and ankle, at the knee, and at one or two points between the ankle Fig. 139. — Varicose veins of the leg; external saphenous branches. and the knee where the middle and upper perforating branches are located. When, for any reason, as congenital weakness or as a result of malnutrition or disease, the walls of a vein become so weakened that it cannot withstand the extra strain of severe and frequently repeated muscular effort, pathologic changes occur. At first a com- 264 SURGERY OF PERICARDIUM AXD HEART pensatory hypertrophy takes place, which may continue for a time and the functions of the vessel remain intact. At a later period this compensation is broken and permanent dilatation takes place with a resulting incompetency of the valves which, in the case of the main trunk of the internal saphenous, gives an enormous increase in the blood-pressure in its lower branches when the patient is standing. from the weight of the unsupported column of blcod. Trendelenburg long ago called attention to the fact that, as the inferior cava, iliac, and femoral veins have no valves, and that if the valves of the internal saphenous become incompetent, the weight of the column of blood from the right heart to the lower subcutaneous vein of the leg is enormous, and will invariably cause dilatation of the inferior tributaries. Compensatory hypertrophy of the subcutaneous veins of the leg and thigh is occasionally seen as a result of femoral or iliac thrombosis. In these cases the main trunk of the internal saphenous is more notice- ably enlarged than the lcwer branches, and the superficial epigastric and circumflex iliac partake in the process, often forming large trunks passing from the saphenous opening to the pubis and abdomen. It is obvious that these vessels should never be disturbed, as the condition is a compensatory anastomosis around the obliterated femoral trunk. The question of involvement of the deeper veins of the leg is an important one, and has been investigated by Gay, Quenu, and others. From their investigations it is probable that it occurs in about one-half of the cases. Not infrequently it occurs with but little evidence of disease in the superficial group. Symptoms. — A moderate degree of varicosity of the superficial veins of the lower leg causes, as a rule, no discomfort. When the valves of the saphenous become incompetent, however, the patient experiences a sense of weight and fulness in the leg and foot, which is promptly relieved on assuming the recumbent posture. In more advanced cases pain is experienced on prolonged standing, and edema of the lower leg and foot may be present. Thickening, bluish discolora- tion, and pigmentation of the skin may occur from chronic passive hyperemia, which also favors the formation of ulcers and eczema. These changes, as a rule, are more marked in the lower half of the leg. This fact serves to distinguish the varicose from the syphilitic ulcer (Fig. 140). The latter, while it may occur in any part of the leg, is more frequently observed in the upper segment. Atrophy of the skin over a mass of varicose veins is occasionally present and predisposed to rupture from some slight trauma. The hemorrhage in such cases is often alarming, both from the large size of the vessel and from the fact that the blood flows from both upper and lower segments of the vein. Where the deeper veins are involved the pain and discomfort are, as a rule, more marked than in the superficial variety. In these cases there is often more edema on standing. Trendelenburg's INJURIES AND DISEASES OF THE VEINS 265 sign is frequently absent and the visible dilatations arc more marked at the points where the deep anastomosing veins join the superficial system. Diagnosis. The diagnosis of varicose veins of the leg often can be made by inspection. When the patient is standing large, tortuous, bluish cords can be seen coursing over the calf of the leg and often extending upward along the inner side of the thigh to the region of the saphenous opening. To determine the question of competency of the valves Trendelenburg's test should be applied. The patient is placed upon his back and the leg elevated to allow the veins to become empty. The finger is then firmly placed over the upper portion of Fig. 140. — Varicose leg ulcer. the long saphenous vein, just below the saphenous opening, and the patient instructed to stand erect. The lower branches will gradually refill from the deeper veins. If, however, the compression of the saphenous is removed, the blood current generally can be seen to course down the main trunk and rapidly distend the branches. If the fingers are placed over the lower portion of the trunk, the downward rush of the blood imparts to the examining fingers a distinct thrill. In cases of marked obesity, and occasionally in cases of moderate dilata- tion of the vein, the descending current of blood cannot be seen, but if the valves are incompetent it can always be felt. Treatment. — A tendency to varicose veins of the leg sometimes can be arrested in the early stages by wearing an elastic stocking 266 SURGERY OF PERICARDIUM AND HEART or by the use of a rubber or flannel bandage. Cardiac lesions causing passive venous congestion should be corrected and the wearing of tight garters avoided. Regarding operative treatment, considerable care should be exercised in the selection of cases. For instance, it would be manifestly absurd to ligate or remove the dilated superficial veins in a case of femoral or iliac thrombosis. Operation is likewise rarely productive of good in those comparatively rare cases where the chief lesion is located in the deep veins of the leg, the superficial group being dilated only in the region of the anastomosing channels. Where there is valvular incompetency, however, and evident involvement of the internal saphenous trunk, operation is to be recommended. A limited removal of the veins is also indicated where they are near the surface and likely to rupture. Three operative methods are at present employed in this condition: Complete removal of the internal saphenous trunk, either by open excision (Madelung) or by the subcutaneous method (Mayo) ; multiple excisions of the main trunk and chief branches; and the Trendelenburg operation. Fig. 141. — Mavo's varicose vein enucleator. Excision of the main trunk of the saphenous is best accomplished by means of the Mayo ring enucleator (Fig. 141 ). The upper segment of the vein is exposed by a short incision, the vein doubly ligated, and divided. The lower portion of the vein is threaded through the ring of the enucleator and held lightly by the left hand of the operator. ^Yith the right the enucleator is pushed downward, severing the vein from its branches, until about eight or ten inches are thus freed. The ring is then pressed firmly against the skin and a small button-hole incision made, through which the freed extremity of the vein is drawn. The enucleator is next removed from the original wound and the same procedure repeated through the second incision. In this manner the entire trunk of the saphenous vein often can be removed through three or four insignificant incisions. The torn branches do not, as a rule, bleed much, and the flow is easily controlled by gentle pressure. This method is the ideal one, and in the writer's experience can be carried out in perhaps one-half of the cases which apply for treatment. In the others it is impossible to remove the vein in this manner on account of its friability or the presence of periphlebitis or calcareous deposits. It occasionally happens that the upper portion of the vein can be removed by the enucleator and the lower portion by multiple excisions. One should strive to remove the greatest amount of the INJURIES AND DISEASES OF THE VEINS 267 pathologic vein through the smallest amount of incision, as long incisions, especially in the edematous tissues of the lower leg, are very likely to become infected. In a large number of cases the method by multiple incisions will be indicated. In this an incision should be made over the highest point of the diseased vessel, the vein isolated, doubly ligated, and a small section removed. Incisions should then be made over the most prominent masses lower down, the vessel excised, the various branches and free extremities of the vein ligated, and the cutaneous wound united. The Trendelenburg method consists in applying an Esmarch bandage to the entire limb, then removing a small section of the internal saphenous vein near the saphenous opening, and keeping the patient in bed until the wound is healed, the theory of its action being that it removes the pressure from the subcutaneous veins of the leg, which gradually regain their tone and diminish in size. This method of treatment is undoubtedly efficacious when the disease is limited to the internal saphenous system, and in the early stages of the malady before the walls of the dilated veins have become permanently thickened. Treatment of varicose veins by injection of coagulating agents into the vein or by acupressure pins is not to be recommended. Nevus, or Venous Angioma. — This affection consists in a mass of dilated capillaries or veins situated in the skin or subcutaneous tissues. The disease is generally congenital, although it is apt to spread and is sometimes first noticed at a later period of life. When the disease is limited to the capillaries it appears as a small red or blue discoloration of the skin which disappears on pressure and quickly returns when the pressure is removed. Occasionally large areas of the skin are involved, making the so-called "port-wine" or "birth" marks. If the smaller veins are involved in the process, the disease appears as an elevated, soft, spongy mass of irregular outline, of bluish or purplish tint, compressible, and rendered more prominent if on the face or neck by crying, coughing, or sneezing. When situated wholly in the sub- cutaneous tissue the discoloration may be slight, only a dusky hue being noticeable on the surface of the mass. In rare instances the disease is associated with an increase in the fatty tissue, making a mixed growth — nevoliporna. Treatment. — When possible, complete excision is to be recommended in the larger venous angiomata, with arrest of bleeding and primary closure of the wound. In the smaller nevi the application of the Paquelin cautery point or of red-hot needles will often bring about a cure. Electrolysis has been successful in small angiomata and in port-wine marks of moderate extent. The method of its application is to introduce two insulated needles into the tumor some little distance apart and to apply through them the galvanic current until the tissues become hardened and white. Several applications are often necessary. The resulting scar is insignificant. Subcutaneous cauterization, either by means of Blake's platinum-pointed cautery needles, which are thrust 268 SURGERY OF PERICARDIUM AND HEART into the tumor from opposite sides, and rendered red hot by contact of the points, which completes the electric circuit; or by the sub- cutaneous injection of boiling water — as recommended by Wyeth— is being largely employed at present with good results. Recently Charles T. Dade has called attention to a new method of treating angiomata which, in the smaller varieties, bids fair to supersede all others. His method consists in freezing the part by direct application of liquid air by means of a blunt cotton swab. Freezing the part with a pencil made of carbon dioxide snow is also efficacious. In the smaller nevi only one application is necessary; in those of larger extent two or three may be required. The application causes only moderate pain and the resulting scar is thin and pliable. The use of the sub- cutaneous ligature was formerly much employed in the treatment of cutaneous angiomata, also the use of pure nitric acid. Both of these methods, however, have been practically abandoned. Y Fig. 142. — Congenital venous nevus. (Halloway.) LIGATION OF ARTERIES IN CONTINUITY. Ligation of arteries in continuity is required for the control of hemorrhage when the bleeding point is inaccessible or the vessels diseased. It is also required to arrest the flow of blood through an aneurism, or as a preliminary procedure in amputations and other major operations when hemorrhage is difficult to control. The instruments required for this operation are a scalpel, two toothed forceps, two retractors, an aneurism-needle, scissors, artery- clamps, needles, and a needle-holder. The materials used for ligature are chromicized catgut, chromicized kangaroo tendon, braided or floss silk. The patient should be placed in such a position as to give the best exposure of the part, the artery should be accurately located by anatomic landmarks, and the tissues divided, layer by layer, until the vessel is reached. When possible, muscles, nerves, and veins should be retracted rather than divided, and layers of fascia, intermuscular septa, and areolar tissue cut rather than torn. Veins which cannot be LIGATIOX OF ARTERIES IS COXTI.X CITY 269 retracted should be divided between two ligatures. When the sheath of the artery is freely exposed, it should be grasped and raised in a transverse fold by two toothed forceps, then carefully opened by scissors or the point of the scalpel, the back of which is directed toward the artery. When the sheath is freely open the artery should be separated from it and the aneurism-needle (Fig. 143) passed around the vessel, threaded with the ligature, and carefully withdrawn (Fig. 144). The ligature should then be tied snugly with a reef or surgeon's knot, the former in superficial vessels, the latter when the vessel lies deeply and when accidental slipping of the knot cannot be readily appreciated. It was formerly supposed that the ligature should be tied with sufficient force to rupture the inner coat of the vessel, but the modern view is that equally good results can be obtained by simply drawing the walls Fig. 143. — Aneurism-neeclle. Fig. 144. — A. opening sheath; B, passing ligature around the vessel; C, tying the artery. together without rupture of any of the coats. The latter method is less likely to be followed by secondary hemorrhage. Some surgeons advise double ligature and dividing the artery between the two knots, for the reason that the arteries are elastic tubes, and are always, under normal conditions, subject to a certain amount of tension, as shewn by prompt retraction of their divided ends when cut. This tension favors rupture of the vessel at a point weakened by the application of a ligature. While these reasons are theoretically correct, this accident practically never occurs in aseptic wounds when ordinary care is used in the application of a ligature to a healthy vessel. After the ligature is tied and cut, the wound should be closed in the usual manner and an aseptic dressing applied. When the main arterial trunk of a limb has been ligated, the extremity should be wrapped in cotton-wool and slightly elevated to favor return venous circulation. 270 SURGERY OF PERICARDIUM AND HEART A good deal has been written in the older text-books about the introduction of the aneurism-needle— that it always should be carried around the artery in a direction away from the most important neigh- boring structure. The rule is a good one, and should be followed under ordinary circumstances; but many other factors may influence the surgeon at the time of operation. In clean, dry wounds in which the structures are freely exposed, it makes little or no difference in which direction the needle is passed. It is well to remember that all the arteries of the upper extremity and all below the knee in the lower extremity are accompanied by two veins, known as venae comites. The arteries of the head and neck except the lingual, the arteries of the thigh, and most of the arteries supplying the thoracic and abdominal viscera, have a single accompanying vein. Above the diaphragm all important venous trunks which accompany the arteries, when not in the same plane, lie above the arteries; below the diaphragm the veins not lying in the same plane lie below the arteries, except the renal. Innominate Artery. — The innominate artery is exposed by an incision along the inner border of the lower third of the sternomastoid muscle, extending one inch below the sternoclavicular articulation. The superficial fascia and platysma are divided, and the anterior jugular vein secured between two ligatures and cut. The deep cervical fascia is split and the attachments of the sternomastoid, sternohyoid, and sternothyroid muscles partly divided, the former drawn outward and the two latter inward by retractors. The sheath of the common carotid is opened and the artery followed downward until the trunk of the innominate is reached. If the bifurcation is low, it will be neces- sary to resect a portion of the sternum and the sternal extremity of the clavicle, to secure enough space to apply the ligature successfully. The innominate vein lies to the outer side and above the artery. Care should be taken in passing the aneurism-needle to avoid the vagus nerve and pleura, which also lie to the outer side of the artery. Carotid Arteries. — Common Carotid Artery. — The common carotid artery is exposed by an incision along the inner border of the sterno- mastoid muscle on a line extending from the sternoclavicular articula- tion to a point midway between the angle of the jaw and the tip of the mastoid process. The incision should extend from a point opposite the upper border of the thyroid cartilage to a point just above the sternoclavicular joint, and should divide the skin, superficial fascia, platysma, and deep fascia. A vein passing from the anterior jugular to the temporofacial vein will be divided; also the sternomastoid branch of the superior thyroid artery. The sternomastoid muscle is retracted outward with the internal jugular vein; the anterior belly of the omohyoid muscle crosses the incision about its middle, passing from above obliquely downward and outward. The arter} r may be tied either above or below this muscle. It is easily recognized by its pulsation, and also by its relation to the carotid tubercle on the LIGATION OF ARTERIES IN CONTINUITY 271 transverse process of the sixth cervical vertebra. The artery lies just above this tubercle at the point where it is covered by the omohyoid muscle. By retracting the sternohyoid and sternothyroid muscles inward and the omohyoid upward, the sheath of the vessel will be exposed in the triangle of necessity; by retracting the omohyoid down- ward and inward the upper portion may be reached in the triangle of election. As the descendens noni nerve lies on the anterior wall of the sheath, this should be opened on the inner wide. If the needle is passed around the artery within the sheath, there is no danger of including the vagus, which lies behind it. External Carotid Artery. — The external carotid artery is exposed by a continuation upward of this same incision. The artery begins at the bifurcation of the common carotid opposite the upper border of the thyroid cartilage, and ends by division into the internal maxillary and temporal, within the parotid gland. It is crossed by the superior thyroid, lingual, and temporofacial veins, by the hypoglossal nerve and the digastric muscle. It is recognized by its numerous branches. It is easily exposed and ligated just above the origin of the superior thyroid branch at a point opposite the great cornu of the hyoid bone. Internal Carotid Artery. — The internal carotid artery is exposed by the same incision as the external carotid. It lies behind and a little to the outer side of the external carotid and can be brought into view by drawing the external well inward. It has no branches. Superior Thyroid, Lingual, Facial and Occipital Arteries. — The superior thyroid, lingual, facial, and occipital may all be exposed and ligated near their origins from the external carotid through this incision. The lingual is often ligated after it passes beneath the hyoglossus muscle; by exposing this muscle by retracting: the submaxillary gland upward and separating its fibres the artery will be found midway between the hypoglossal nerve and digastric tendon, running inward parallel with the nerve. The facial artery may also be exposed and tied as it crosses the lower border of the jaw just in front of the masseter muscle. A short horizontal incision, including the skin, fascia, and platysma, will expose the artery and vein. Temporal Artery. — The temporal artery may be exposed as it crosses the zygoma just in front of the external auditory meatus. It lies beneath the skin and fascia, and is in relation to the auriculotemporal nerve, which should be recognized and avoided in passing the ligature. Subclavian Artery. — The subclavian artery can be safely exposed and ligated in its third portion or that part which passes from the outer border of the scalenus anticus muscle to the lower border of the first rib. The patient should lie on his back on the table with a sand-bag under the shoulder; the head should be turned to the opposite side and the arm drawn well downward. A horizontal incision three inches in length should be made over the clavicle, after drawing the skin well downward to avoid the external jugular vein. When the skin is relaxed the incision will appear half an inch or more above the bone. 272 SURGERY OF PERICARDIUM AND HEART The superficial fascia, platysma, and one or two superficial veins will he divided, also the deep fascia. If the space between the trapezius and sternomastoid muscles is too narrow, these should be partly divided at their attachment to the clavicle and well retracted. The external jugular vein, and occasionally other large branches, should be carefully retracted or divided between two ligatures, the omohyoid muscle located and drawn upward. The artery can be recognized by its pulsation, passing outward from behind the scalenus anticus muscle, lying on the scalenus medius and first rib. The subclavian vein lies in front and below, the brachial plexus above and to the outer side. These structures and the pleura should be avoided in passing the needle. Vertebral Artery. — The vertebral artery may be exposed by an incision along the posterior border of the lower half of the sternomastoid muscle. This incision includes the skin, superficial fascia, platysma, and deep fascia. The sternomastoid is retracted inward, the scalenus anticus muscle recognized, and the space between it and the longus colli muscle cleared. The artery lies just below the transverse process of the sixth vertebra. The vein lies anteriorly and should be retracted. The ligature occasionally includes some fibres of the sympathetic, which would be indicated by a subsequent contraction of the pupil. Inferior Thyroid Artery. — The inferior thyroid artery may be ex- posed through the incision for ligature of the common carotid in the triangle of necessity. After the carotid sheath is exposed, it is retracted outward with the sternomastoid muscle, the sternohyoid and sterno- thyroid muscles and the thyroid gland are drawn well inward, and on the floor of the space thus formed the inferior thyroid artery will be seen passing inward just below the transverse process of the sixth cervical vertebra. It should be ligated as far outward as possible to avoid the recurrent laryngeal nerve. Axillary Artery. — The axillary artery may be ligated in its first and third portions. The first part is exposed by an incision, horizontal or slightly curved upward, just below the clavicle, from the inner border of the deltoid, to a point near the sternoclavicular articulation. The clavicular fibres of the pectoralis major are divided and the tendon of the pectoralis minor exposed. The costocoracoid membrane is next divided and the acromial thoracic artery and the cephalic vein followed downward to their junction with the main trunks. The artery can be recognized by its pulsation and by its position below the cords of the brachial plexus and above the vein. The third portion of the artery is exposed in the axilla. The arm is held at a right angle with the body and an incision three inches in length is made along the course of the artery, which can be easily located by its pulsations. Division of the skin and fascia will expose the vein, which lies above and to the inner side of the artery. The ulnar and internal cutaneous nerves lie to the inner side below the vein, the musculocutaneous to the outer side, and the median just LIGATION OF ARTERIES IN CONTINUITY '27'.] above the artery. These should be retracted, the venae comites separated from the artery, and a ligature applied below the origin of the circumflex branehes. Brachial Artery. — The brachial artery lies just beneath the skin and fascia along the inner border of the biceps muscle, corresponding with a line drawn from the junction of the anterior and middle thirds of the outlet of the axilla to the middle of the bend of the elbow. The vessel is exposed in the middle of the arm by an incision along the inner border of the biceps muscle, dividing the skin and fascia. The artery is easily recognized by its pulsations. The median nerve lies upon the artery and should be retracted. The sheath is next opened and the ligature placed about the vessel, care being taken to avoid the vena? comites. At the bend of the elbow the artery can be easily exposed by a short oblique incision along the inner side of the biceps tendon parallel with the median basilic vein. The bicipital fascia is divided and the artery with its venae comites exposed. Radial Artery. — The radial artery may be exposed at any part of its course in the forearm, or in the tabatiere between the extensor tendons of the thumb. The line of the artery extends from the middle of the bend of the elbow to a point midway between the tendons of the flexor carpi radialis and the palmaris longus at the wrist. In the middle and upper part of the forearm the artery is reached by an incision along the line of the vessel. After division of the skin and fascia the inner border of the supinator longus muscle is found and retracted outward. This exposes the vessel and its vense comites. The radial nerve lies to the outer side of the artery. In the lower third of the forearm the artery lies between the tendons of the supinator longus and flexor capi radialis, and may be easily reached by an incision which exposes these structures. In the tabatiere the artery may be exposed by an oblique incision in the triangular space between the extensor tendons of the thumb. A superficial vein is encountered which may be retracted or divided. The artery lies immediately below the deep fascia. Ulnar Artery. — The ulnar artery can be exposed at the bifurcation of the brachial by an oblique incision just below the bend of the elbow along the upper border of the pronator radii teres muscle and retracting the muscle inward. The artery is reached by following the brachial downward. In the middle of the forearm the artery lies beneath a line extending from the tip of the internal condyle to the outer side of the pisiform bone. An incision is made along this line dividing the skin and superficial fascia. The white line of the intermuscular septum between the flexor carpi ulnaris and the flexor sublimis digi- torum is found and the muscles separated. The artery with the accompanying vena? comites will be found at the bottom of the wound. The ulnar nerve lies to the inner side of the artery. Above the wrist the artery is easily reached by an incision along the same line, just to the outer side of the tendon of the flexor carpi ulnaris. After the 18 274 SURGERY OF PERICARDIUM AND HEART deep fascia is incised and the tendon of the ulnar flexor drawn inward, the artery is easily found and ligated. The ulnar nerve lies to the ulnar side of the artery. Abdominal Aorta. — The abdominal aorta has been ligated on several occasions for hemorrhage or aneurisms of its lower segment or of the iliac arteries and the procedure is still regarded by surgeons as a justifiable experiment in certain cases. The vessel may be reached by two routes, the abdominal and the retroperitoneal or lumbar. The former is to be preferred, not only on account of the ease of its perform- ance, but also for the reason that the latter is associated with grave danger of sloughing of the colon from accidental injury to the branches of the inferior mesenteric artery. An incision is made just to the left of the median line opposite the point selected for the ligature and the abdominal cavity freely opened. The small intestine is drawn aside and retained by gauze pads. The vessel is recognized by its size and pulsations. The parietal peritoneum is divided and the aneurism-needle passed around the artery in such a maimer as to avoid injuring the sympathetic plexus which surrounds the vessel. Floss silk or flat kangaroo tendon should be used for the ligature, and the knot should be drawn with only sufficient force to cause arrest of the flow of blood, and not to injure the vessel walls. In case of aneurism a temporary ligature is indicated, and is not necessarily drawn sufficiently tight to occlude the lumen of the vessel completely. Hiac Arteries. — Common Iliac Artery. — The common iliac artery may be reached by a transperitoneal incision through the median line or along the outer border of the rectus muscle. The intestines are packed aside and the vessel easily recognized by its pulsation. In dividing the peritoneum over the vessel care should be taken to avoid wounding the ureter, which crosses the vessel near its bifurcation. The iliac vein lies below and to the right of the artery. The Trendelenburg posture is to be recommended in this operation. The operation generally employed to expose this vessel is by the curved inguinal incision of Mott for exposing the iliac vessels. This incision begins one inch above the centre of Poupart's ligament, and is carried upward and outward in a curved direction, keeping about one inch to the inner side of the ligament and the anterior superior spinous process of the ilium, then carried upward and slightly inward toward the umbilicus. The incision is about eight inches in length, and is carried downward through the various muscular layers and transversalis fascia until the subserous fat is reached. The peritoneum is then carefully separated from the iliac muscle and retraced toward the median line until the psoas muscle and iliac vessels are freely exposed. The ureter is generally raised from the vessel with the peritoneum. By retracting the edges of the wound a good view of the common and external iliac vessels can be obtained, and a ligature can be applied at any point. Internal Iliac Artery. — The internal iliac artery is reached best by means of a transperitoneal median incision below the umbilicus, the LIGATION OF ARTERIES IN CONTINUITY 275 patient being in the Trendelenburg position. The artery can be recognized by tracing it downward from the common iliac. Care should be taken to avoid wounding the ureter and the accompanying vein. External Iliac Artery. — The external iliac artery can be exposed by the transperitoneal operation or by the incision of Cooper, which is practically the same as the lower four inches of the Mott incision described above for the common iliac artery. When the peritoneum is retracted, the artery is seen lying upon the inner border of the psoas muscle. The vein lies to the inner side of the artery, and the anterior crural nerve to the outer side, the genitocrural on the vessel. High up it is crossed by the vas deferens, and occasionally by the ureter. The writer has exposed the artery for temporary compression on several occasions by the intermuscular method, following the McBurney procedure for interval appendectomy until the peritoneum is reached, then stripping it from the iliac muscle as in the Cooper operation. The artery can be exposed by this method throughout its entire extent and can be easily ligated. After ligation the tissues fall together, and it is only necessary to unite the aponeurosis of the external oblique and the skin. Gluteal Artery. — The gluteal artery may be exposed by an incision on a line passing from the posterior superior spinous process of the ilium to the great trochanter. The artery emerges from the sciatic notch above the pyriformis muscle opposite the junction of the upper with the middle third of this line. The fibres of the gluteus maximus and medius should be separated and well retracted. The gluteal nerve lies below the artery. Sciatic Artery. — The sciatic artery emerges from the pelvis below the pyriformis muscle with the sciatic nerve and internal pudic artery, at a point opposite the junction of the lower and middle thirds of a line drawn from the posterior superior spinous process to the tuberosity of the ischium. It can be exposed by a perpendicular or oblique incision. Femoral Artery. — Common Femoral Artery. — The common femoral artery is only about one and one-half inches in length. Its position and that of the superficial femoral may be indicated by a line drawn from a point on Poupart's ligament midway between the anterior superior spinous process and the symphysis pubis to the adductor tubercle on the inner condyle of the femur. The incision should be made along the line beginning half an inch above Poupart's ligament and extending three inches below that point. The superficial veins should be retracted or divided, the deep fascia opened, the artery recognized by its pulsations, the sheath incised and the needle passed away from the vein, which lies to the inner side of the artery. Superficial Femoral Artery. — The superficial femoral artery in Scarpa's triangle is exposed by a similar incision carried further downward, and ligated in the same manner. The superficial femoral 276 SURGERY OF PERICARDIUM AND HEART artery in Hunter's canal is exposed by an incision three or four inches in length along the line of the artery in the middle third of the thigh. The deep fascia is incised and the sartorius muscle recognized and retracted inward. The roof of the aponeurotic canal is exposed by this retraction and is opened on a director. The artery is easily felt and separated from the vein, which lies behind and to the outer side of it. The long saphenous nerve crosses the artery from without inward. Popliteal Artery. — The popliteal artery may be exposed by an inci- sion along a line drawn from a point just inside the inner hamstring above, to the middle of the lower part of the popliteal space below. The skin, superficial, and deep fasciae are divided, and the artery recognized by its pulsations. If ligation is to be performed in the upper part of the space, the nerve and vein will be found to the outer side of the artery, and should be drawn outward. If the lower portion of the artery is to be ligated, the nerve and vein will be found to the inner side of the artery, and should be retracted inward. In this operation the external saphenous vein, the external saphenous nerve, the plantaris muscle, and the sural arteries will be exposed and must be avoided. Tibial Arteries. — Anterior Tibial Artery. — The anterior tibial artery may be exposed in any part of its course by an incision along a line drawn from a point midway between the head of the fibula and tuber- osity of the tibia to a point opposite the middle of the front of the ankle. The incision should divide the skin, superficial fascia, and deep fascia. The line of division between the tibialis anticus and extensor proprius pollicis should be recognized and the two muscles separated and held well apart. The artery will be found at the bottom of the space thus formed, lying on the interosseous membrane. The nerve lies to the outer side of the artery. In the upper third of the leg the white line between the two muscles may not be distinctly seen. In this case a small arterial branch may sometimes be found between the two muscles, which will serve as a guide. The intermuscular septum lies from three-quarters to one inch from the crest of the tibia. Posterior Tibial Artery. — The posterior tibial artery follows a line drawn from the middle of the lower part of the popliteal space to a point midway between the tendo Achillis and the internal malleolus. It can be ligated in the middle of the leg through an incision a finger's breadth behind the inner border of the tibia. This should expose the long saphenous vein and nerve, which should be retracted. The deep fascia is next split and the edge of the gastrocnemius muscle drawn aside. The tibial attachment of the soleus is recognized and divided at a point half an inch from the bone. Beneath this the vessels and nerve will be found enclosed in a process of the deep fascia lying on the flexor longus digitorum muscle. The nerve lies to the outer side of the artery. The artery is exposed at the ankle by a semilunar incision midway between the tendo Achillis and the internal malleolus, LIGATION OF ARTERIES IN CONTINUITY 277 following the curve of the latter. The artery is superficial in this position, and lies just beneath the deep fascia. The nerve is external to the vessel. Care should be taken to avoid opening the tendon sheaths. Peroneal Artery. — The peroneal artery may be exposed by an inci- sion along the posterior border of the fibula, dividing the skin and fascia, retracting the gastrocnemius muscle, and incising the tibial attachment of the soleus. The artery lies near the fibula just beneath the deep fascia. Dorsalis Pedis Artery. — The dorsalis pedis artery is exposed by an incision along a line drawn from the centre of the front of the ankle to the upper part of the first interosseous space. The vessel lies between the tendons of the extensor proprius pollicis and extensor longus digitorum, and sometimes is covered by the extensor brevis digitorum. CHAPTER XII. INJURIES AND DISEASES OF THE LYMPHATIC SYSTEM. INJURIES OF THE LYMPH CHANNELS. As lymphatics are present in every organ and tissue of the body, every wound, cut, or severe contusion must necessarily be associated with injury to some lymphatic structure. Unless the injury involves the largest and most important lymph vessels, however, little or no disturbance results, and no special treatment is required. Injuries of the thoracic duct or its larger mesenteric branches (lacteals) may result from severe traumata, as fractures of the spine, severe crushes or contusions 'of the thorax and abdomen. These injuries are not infrequently fatal from failure of a large amount of the nutritive products of digestion to reach the blood. In such cases the chyle collects in the abdomen, pleura, or in the retroperitoneal or retropleural connective tissue, forming chylous ascites, chylothorax, or large retro- peritoneal collections of chylous fluid, which may become infected, burrow, and point in the groin or in other remote situations. Acci- dental injuries of the thoracic duct at or near its terminal delta in the neck have occasionally occurred as the result of surgical procedures. The pathognomonic symptom of this injury is the sudden flooding of the wound with a milky fluid, which issues from the region of the junction of the deep jugular and subclavian veins. Treatment. — The treatment of chylous ascites or chylothorax has up to the present time been simply the employment of means to remove the fluid from these cavities to overcome the untoward effects of pressure. In several instances this has eventually been followed by a cure. Laparotomy with a view to locating and seeming the leaking vessel would be indicated in a case of chylous ascites which persisted after one or more tappings. In accidental wounds of the cervical portion of the thoracic duct the leaking point should accurately be located, clamped and ligated, and the wound closed in the usual manner. In the majority of instances in which this plan has been carried out no untoward results have followed, probably for the reason that only one of the several terminal branches of the duct was injured; or, if the main duct was ligated, the anastomosing channels which are usually present between the duct and the upper two or three intercostal veins subsequently dilated and carried on the circulation. DISEASES OF LYMPH CHANNELS AND LYMPH NODES. General Discussion. — It is important in dealing with the affections of the lymphatic system to have a clear understanding of the general DISEASES OF LYMPH CHANNELS AND LYMPH NODES 279 structure, its relation in particular to the intercellular spaces, the structure of the nodes and their relation to the blood- vascular system. In the accompanying diagram (Fig. 145) the general arrangement of the system is portrayed quite without any reference to relative General systemic ci7'culatio7l Fig. 145. — Diagrammatic drawing to illustrate the general architecture of the lymphatic vessels and nodes with reference to the tissues and the blood-vascular system. a, efferent lymph vessel entering the vein; b, vein from lymph node; c, efferent lymph vessel; d, hilum; e, capsule; /, lymph cord; g, lymph sinuses between nodules and cords; h, lymph nodules; i, circular sinus; j, afferent lymph vessel; k, lymphatic capillary loop; I, epithelial surface; m, indicating a second lymph node interposed between the first and the venous system; n, lungs; o, heart; p, artery to the lymph node; q, connective-tissue framework; r, delicate connective-tissue strands traversing the sinuses to join the reticulum of the nodule; they are lined by the endothelium of the sinus; s, tissue cell; t, intercellular spaces; u, transition between arterial and venous capillary. size of structures. An endothelial lined, lymphatic, capillary loop is shown in the intercellular spaces between body cells not far from an epithelial surface. In this same area an arterial capillary is in trans- ition to a vein. An afferent lymphatic vessel runs from the loop to the periphery of a lymphatic node, entering, together with other 280 INJURIES AXD DISEASES OF LYMPHATIC SYSTEM similar trunk-, the circular sinus that extends about the greater part of the periphery of the node. From this circular sinus the endothelial lined, lymphatic channels run about the periphery of the nodules, then about the lymph cords to fuse at the hilum into the efferent vessel which is then portrayed as passing through a second similar system of nodes and thence into the venous system. The artery and veins to the lymph node are shown entering and leaving the hilum and cours- ing along the connective-tissue trabecule that acts as a supporting framework for the node structures. Tiny trabecuhe lined by endothelial • til- transmit bloodvessels to the nodules by traversing the lymph sinuses. The connective-tissue cells in these trabecular are continuous with the delicate reticulum that exi>t> as a supporting framework for the lymph nodules. The lymphoid cells and so-called germ centres are portrayed in th<- nodule. The bloodves-els are shown, for simplicity's sake, entering only one nodule and one lymph cord. Let us imagine the presence of an irritating substance 'for instance, a pathogenic micro-organism) in the intercellular spaces of the area /. Let us follow the possible effects with special reference to the lymphatic system. The chemistry and physical properties of the intercellular fluids will be altered, and the nutrition of the neighboring cells inter- fered with. Bearing in mind the vast and complicated number of local changes that may occur, with an inflammatory process, such as those associated with exudation of cells and serum, formation of fibrin, the appearance of ferments, such as leukoprotease, etc., as demonstrated by Opic — and other changes, such a- those that have been elucidated by the work of Yaughan and many others — irritating substances may be distributed to other parts of the body, either by extension along the intercellular spaces locally, by the blood capil- laries, or by the lymphatic capillaries. As irritating substances pa — along the main lymphatic afferent vessels the reaction produced in the tissues just outside of the vessel wall may cause a superficial appearance of inflammation, with the characteristic red streaks well known in cases of acute lymphangitis. It has been demonstrated, with consider- able substantiation of the theory, that at the outset of an acute inflam- matory process the patent viable lymph sinuses in the nodes act as channels through which irritating substances may reach the blood stream practically unchanged and without restraint. Observers have spoken of this process as the "initial rush" through the lymphatics. Clinical observations lend support to this theory. Very shortly, however, after the arrival of irritating substances in the lymph sinuses a very extensive increase in the number of lymphoid cells and cells that have exuded from the bloodvessels appear in the nodules. The sinuses are filled with varying types of phagocytes. If the substances are very irritating and their supply small we speak of this condition as an acute hyperplasia. If the process is prolonged and the substances are less irritating we speak of a chronic hyperplasia. It is well to consider that in the intercellular spaces between the lymphoid cells DISEASES OF LYMPH CHANNELS AND LYMPH NODES 281 of the nodules and cords there is, as it were, a common meeting ground for the fluids and cells derived from the original sources of irritation through the lymph channels, and the fluid or cells derived from the systemic blood-vascular system. Besides these two factors is the enormous hyperplasia of lymphoid cells that occurs in the same area. The lymph that has passed through the node or a series of nodes by their efferent vessels into the veins has accordingly had ample oppor- tunity for modification. Going a step further, let us imagine venous blood that is receiving continuous minute doses of these modified irritating substances. It passes to the lungs, receives oxygen and is then distributed to all parts of the body, there to be modified by the various organs and tissues, finally to return tremendously diluted through the artery of the lymph node and there distribute its effects, modified by its journey, in the intercellular spaces of the nodule. It is strongly suggestive that in these intercellular spaces of the lymph nodules one of the most important laboratories in the body may exist for the elaboration of immune substances. Lymphangitis; Lymphadenitis. — A certain amount of lymphangitis is present in the neighborhood of all infected wounds, and cellulitis, and has been described in Chapter X. As the function of the lymph nodes is to arrest or modify infectious matter carried upward through the lymph channels toward the blood, and to hold this poisonous material until the local process has subsided or until the blood is capable of neutralizing or eliminating it, the nodes become enlarged, tender, and often acutely inflamed during the progress of a septic inflammation in the region drained by their afferent channels. Certain forms of infection have apparently little tendency to cause inflammation in the lymphatic vessels or nodes; while others, as those due to the streptococcus group of micro-organisms, attack at once the lymphatic structures, spread rapidly along the channels, and cause early enlarge- ment of the nodes. Symptoms. — The symptoms of lymphangitis are pain, tenderness, and the presence of lines or patches of redness and edema extending upward along the chief lymph vessels toward the trunk. The lymph nodes along the course of these vessels enlarge, become tender to the touch, and may be surrounded by an area of redness and edema of the skin and cellular tissue. With these local symptoms there is generally considerable systemic reaction, evidenced by chills, fever, headache, general malaise, and more or less prostration. In the milder cases these symptoms rapidly subside as soon as the original source of the infection is removed and secondarily infected areas are opened and drained. In the severer cases, when the original infection is a virulent one, as an autopsy or other poisoned wound of the finger, the general symptoms may precede by several hours the local mani- festations, due to the so-called initial rush, and a high grade of septic intoxication or even true septicemia may develop. Clinically, injuries, such as contusions of tissues through which chronically inflamed 282 INJURIES AND DISEASES OF LYMPHATIC SYSTEM lymphatic trunks have their course, may result in infection due to the extravasation of bacteria, or cells containing bacteria from the ruptured lymph vessels transmitting them. Extensive and often mul- tiple areas of suppuration follow lymphangitis, due to perivascular cellulitis or glandular abscess. Treatment. — The treatment of lymphangitis in the early stages should consist in removal, if possible, of the original focus of infection, and the application of a dressing of 20 per cent, ichthyol ointment, of mer- curic chloride (1 to 5000) or of aluminium acetate to the inflamed areas. This is often promptly successful. The primary focus of infection should be treated and incised if necessary. Should the lymphangitis become a diffuse cellulitis or abscess, it should be treated as such. Excision of lymph nodes in acute lymphangitis is to be condemned; incision is indicated only with abscess formation or very severe and rapidly spreading infections. Acute lymphadenitis is of necessity associated sooner or later with acute lymphangitis. The nodes become enlarged and tender. They usually subside with proper attention to the source of infection. Small abscesses may form, however, coalesce and with extension to the surrounding tissues form one large abscess. This often occurs in the neck, the axilla, and the groin. They can generally be opened through rather small incisions, inasmuch as the process is well walled off, and as soon as the pus effects an exit, repair is rapid. Obstruction of the Lymph Channels. — Obstruction of the lymph channels may be due to inflammatory processes, to the pressure of new growths, to the presence in the lymph channels of a parasite, Filaria sanguinis hominis, to the excision of all the nodes and portions of their afferent channels, as in the close stripping of the axillary vein in operations for mastectomy, or to congenital conditions the nature of which is not understood. Obstruction of the lymph channels may result in lymphedema, or swelling of all the lymph channels and spaces over a large area, or to localized swellings or vascular dilatations. Lymphedema, or Elephantiasis. — Lymphedema, or elephantiasis, is a condition of hypertrophy of the skin and cellular tissue resulting in great deformities. It is of frequent occurrence in tropical countries, where it is generally due to Filaria sanguinis hominis. It affects chiefly the lower extremities the external genitals of both sexes, occasionally the arms and other parts of the body. In many instances elephantiasis of filarial origin is observed without the presence of embryos in the blood. In these cases it is probable that the parent worms occupy the main lymphatic channels of the affected limb, and by their presence cause an obliterative inflammation which prevents their embryos gaining entrance to the general lymph or blood streams. The chief pathologic factors in elephantiasis are, first, an obstructed lymph current, and second, an enormous overgrowth of connective tissue. The skin becomes exceedingly thick, coarse, pigmented, and thrown into folds and creases. There is often a foul discharge with a DISEASES OF LYMPH CHANNELS AND LYMPH NODES 283 tendency toward the formation of ulcers. The same condition is not infrequently seen in the foot and lower leg of an individual suffering from chronic ulcer when the ulcer is extensive and nearly encircles the limb (Fig. 146). Gerrish has reported an example of elephantiasis of the scrotum due to the pressure of a double truss worn for the relief of hernia. Symptoms. — The symptoms of elephantiasis are at first only an edema and moderate enlargement of the limb. Later there occur attacks of dermatitis, or erysipelas with fever, lumbar pain, and general malaise. This causes a thickening of the skin which, as the subcutaneous areolar tissue hypertrophies, forms creases and folds in which dirt, sebaceous material, and moisture collect, giving Fig. 146. — Old ulcer of the leg with lymphedema. rise to a foul-smelling and irritating discharge. In many instances the increase in size of the affected part is enormous, and constitutes a disfiguring and burdensome deformity. These extreme examples of the disease are rarely seen in temperate climates, but in some tropical countries where filariasis is common a fair proportion of the inhabitants suffer from the malady. In many cases the diagnosis can be made by finding the parasites in the blood of a patient at night, or sometimes in the daytime after rest in bed. Treatment. — The treatment of this condition is unsatisfactory. In some instances, in the early stage of the affection, elevation of the limb, massage, and bandaging may be of temporary benefit. As a rule, however, surgical advice is not sought until the disease is well 284 INJURIES AXD DISEASES OF LYMPHATIC SYSTEM advanced. Warm baths and care in the cleansing of the cutaneous creases and pockets is essential for the prevention of infection. Oper- ative treatment is to be recommended when the disease becomes burdensome. The ideal procedure is to remove the primary site of infection if it can be located and excised. This is rarely possible. In a number of cases of elephantiasis of the lower limb, much can be accomplished by removal of large wedge-shaped areas with subsequent closure of the wounds and aseptic healing. In this manner limbs can sometimes be rendered useful, which before operation were a serious impediment to locomotion. The employment of multiple setons for lymphedema has recently been suggested, and considerable improve- ment has followed their use, especially in the swollen arms which not infrequently follow a complete breast amputation. In some instances amputation is to be recommended. If the disease affects the scrotum or labia majora, complete or partial ablation is to be advised. In all operative procedures upon these cases great care should be exercised in regard to hemostasis, as the vessels, particularly the veins, are enormously enlarged and hemorrhage is often alarming. Localized Lymphatic Dilatations; Lymphangiomata. — In this con- dition the dilated lymph vessels resemble the angiomata of blood- vessels, except that the mass is colorless. The disease may affect the lymphatic capillaries or the larger vessels, giving rise in the former instance to small areas of colorless dilated lymphatics, the so-called lymphatic nevi; in the latter to cavernou> lymphangiomata, irregular compressible tumors made up of masses of dilated lymph vessels. The etiology of these conditions is obscure; a certain number of the eases of lymphangiomata which occur in the scrotum, groin, and in the retroperitoneal lumbar region are undoubtedly due to Filaria sanguinis hominis. These are often associated with lumbar pain, severe intermittent fever, chyluria, hematuria, and occasionally chylous hydrocele. Macroglossia, macrocheilia, and macrodactylia, or enlargements of the tongue, lips or fingers, are occasionally encountered as congenital affections due to lymphatic obstruction. Treatment. — The treatment of all these conditions is rather unsatis- factory. Electrolysis is to be advised in the smaller lymphangiomata. In the larger tumors excision is to be attempted. Even the largest sometimes may be removed and the deformities thus created repaired by plastic procedures. As in the case of hemangiomata, small lymphangiomata can be successfully treated by liquid air. Tuberculosis of the Lymph Nodes. — Tuberculosis of the lymph nodes is of frequent occurrence. As in cases of septic infection, the nodes act as barriers and temporarily arrest the transit of infectious material toward the general circulation. Where the primary focus of absorption is small and the resistance of the individual great, the nodes may enlarge, remain stationary for a period, until the original source of infection is removed or disappears, and then gradually disappear, the infectious material which they contain being destroyed DISEASES OF LYMPH ' H ANN ELS AND LYMPH NODES 285 by the bactericidal elements of the economy. It has beeD claimed by many observers that most cases of cervical lymph node tuberculosis are due to an infection by the bovine type of tubercle bacilli. When the condition- arc less favorable to spontaneous resolution, the disease gradually results in destruction of the node-, the development of periadenitis, with involvement of the surrounding areolar tissue, fascia, and muscle. In the early stages of the affection there is appar- ently a simple hypertrophy of the nodes, which on cut section present only a pinkish or gray homogeneous appearance. Later, cheesy foci develop and the entire node may caseate and liquefy, or, as a result of secondary infection, an abscess may develop and discharge spon- taneously, leaving a chronic fistulous tract leading to a necrotic and partly disorganized lymph node. The disease occur- most frequently in the cervical region, the source of infection being located in the oral, pharyngeal, or nasal cavity. It also occurs in the bronchial or medias- tinal nodes from some tuberculous focus in the lung; in the mesenteric lymphatics, from some focus in the intestine; in the nodes of the groin, axilla, or lumbar region, from foci in the tissues drained by their afferent vessels. Tuberculosis of the Cervical Lymph Nodes. — This condition is of com- mon occurrence, and gives rise to deformity, for the relief of which the surgeon is frequently consulted. In the majority of instances the disease arises from some focus in the pharyngeal or faucial tonsil. It is impossible to state with certainty the source of infection of all cervical tuberculous nodes. Likely sources of infection may be a carious tooth, a suppurating middle ear, or some other open lesion of the nose, mouth, or scalp. It has also been demonstrated experi- mentally that a tuberculous infection of a cervical lymph node may follow the application of tubercle bacilli to the nasal mucous membrane without giving rise to a local lesion i Cornet). A glance at Plate XI will show the general arrangement of the lymph nodes of the neck. Of the five superficial groups, the occipital group receives lymph from the back of the neck and posterior portion of the scalp; the mastoid group and those lying on the external surface of the upper third of the sternomastoid muscle, from the parietal region of the scalp and posterior part of the meatus and external ear; the parotid group, divided into the deep group that is situated in and posterior to that portion of the gland projecting deep into the neck beneath the pterygoid muscles, and the superficial group scattered extensively throughout that portion of the gland in front of the ear, and beneath the deep fascia, the former from the posterior naso- pharyngeal region, the latter, from the anterior part of the auricle, the temporal region, and upper part of the face; the submaxillary, from the lateral aspect of the lips, gums, teeth, anterior half of the tongue, and floor of the mouth; the submental, from the same regions, but nearer the median line. It is noteworthy that the submaxillary salivary gland does not have lymph nodes developed in its substance 286 INJURIES AND DISEASES OF LYMPHATIC SYSTEM normally as does the parotid. The deep cervical group of lymph nodes which lies beneath the sternomastoid muscle along the internal jugular vein receives the lymph from all of the superficial groups, and extends downward to the junction of the jugular and subclavian veins. It also receives direct channels from the tongue, palate, pharynx, nasal fossae, and larynx. A knowledge of these facts will often enable one to find the original source of infection when dealing with malignant, septic, or tuberculous involvement of the cervical nodes. Symptoms.— The symptoms of this condition are, at first, a painless enlargement of one or more lymph nodes, which present no evidences of acute inflammation. They feel firm, are discrete, and freely movable. Later, they become larger and adhere to each other and to the surround- ing structures, giving rise to irreg- ularly shaped tumors which are more or less fixed. Fluctuation may develop or, if secondary infection occurs, the surrounding skin be- comes red and infiltrated. There is at first no apparent effect on the gen- eral health, in fact it is remarkable how frequently tuberculous cervical lymph nodes occur in individuals who are otherwise in the most per- fect health: but later there may be anemia, and fever; night-sweats, and wasting may occur in the later stages. In other cases the disease seems to follow an acute septic involvement of the nodes, as after scarlet fever, acute tonsillitis, or diphtheria. A diminished resist- ance to tuberculosis occurs with measles, influenza and whooping- cough. In these instances it is probable that the nodes were already infected by the tubercle bacilli, and that the process was stimulated by the septic invasion. As a rule, the first nodes to become enlarged are those in the sub- maxillary region or those situated about the upper third of the internal jugular vein. As the disease progresses the nodes lower down in the chain become involved, also those situated behind the sternomastoid muscle, and in the posterior cervical triangle. In advanced cases the entire lateral aspect of the neck may present an irregular nodular enlargement (Figs. 147, 148, and 149). When suppuration occurs, which is generally the result of a mixed infection, the skin becomes red Fig. 147. -Tuberculous lymph nodes of neck. DISEASES OF LYMPH CHANNELS AND LYMPH NODES 287 and edematous, fluctuation develops, and spontaneous rupture may occur. The resulting sinus may remain open for an indefinite period, Fig. 148. — Solitary lymph node of neck. and its external opening is often surrounded by a pouting purple area of infiltration (scrofuloderma). Prognosis. — In a number of cases spontaneous recovery follows a change to more favorable hygienic surroundings. Arrest of the process, but with little tendency to resolution, is more frequently Fig. 149. — Multiple tuberculous lymph nodes of neck and face. observed. In a number of late reports, made by careful observers in cases treated medically, it has been shown that from 20 or_40 per 288 INJURIES AND DISEASES OF LYMPHATIC SYSTEM cent, eventually develop tuberculosis of the lungs or other important organs. The results following incomplete surgical operations show little to encourage the timid operator, but in those clinics where thorough and painstaking surgical procedures are carried out, the percentage of recoveries is from 75 to 90. Treatment. — In the treatment of this disease, as in other tuberculous conditions, certain hygienic measures should always be adopted if the best results are to be obtained. Life in the open air — particularly at the seashore or mountains — sleeping out of doors, or in rooms with wide-open windows, and abundance of good, nourishing food, carefully supervised exercise with prolonged hours of rest and sleep, avoidance of irritation to the probable source of infection, and sometimes elastic rubber-tube constriction about the neck, as recommended by Bier for passive hyperemia, will not infrequently result in a spontaneous disappearance of the enlarged nodes without other treatment. Surgical Treatment. — If after a period of observation under careful conservative treatment there is no evidence of improvement, the general rule to excise entirely, where possible, a tuberculosis focus holds good. But the lymph node may not be the only focus or even the main focus. The removal of a chronically inflamed tonsil or mass of adenoid tissue from the phalanx, may remove the source of infec- tion, or perhaps a persistent source of irritation to the nodes. If this has been done and the enlargement of the nodes persists, radical enucleation should be advised. When the infection has not yet progressed to the tissues outside the nodes, this is comparatively simple, Other conditions, however, may obtain. 1. There may be extensive adhesions binding groups of nodes together and to surrounding structures in atypical masses. In these cases a bloc dissection should be performed. It may be long and difficult and involve division of sternomastoid muscle below the spinal accessory, and occasionally resection of the jugular veins. 2. Shutting off of blood supply, areas of coagulative necrosis either as single, large, or multiple, smaller, cold abscesses may develop, confined either to single nodes or all the nodes of a single group, or to many nodes in many groups. As complete an excision as possible and care to obliterate all dead spaces is here indicated. 3. Extension of the tuberculous infection to the tissues outside the nodes causing a diffuse tuberculous cellulitus with or without large areas of coagulative necrosis. Here, again, excision should be com- plete, and where impossible, by as thorough removal as possible with a sharp curet. In this type there frequently occur: 4. Tuberculous sinuses. These should be conservatively treated by measures calculated to keep the sinuses scrupulously clean. Elimi- nation of secondary pyogenic infection, stimulation and increasing the blood supply to the tract. This is often favored by the use of the Bier cups. Frequent dressings, occasional instillations of pure carbolic acid, DISEASES OF LYMPH CHANNELS AND LYMPH NODES 289 cupping, sometimes the use of tincture of iodine, and, if the eavity is not too large, injections of Mosetig-Moorhof s iodoform emulsion (care being taken not to inject too much) are all useful. The dressing and care of a tuberculous sinus is one of the most interesting of out- patient problems. The general hygienic measures are of the greatest importance in these cases. 5. Pyogenic infection of already existing tuberculous lymph nodes. These cases, frequent in children, generally show a fluctuating, red- dened, tender abscess pointing through the skin. A very minute incision suffices for drainage. Later the nodes may be removed. Fig. 150. — -Two transverse incisions for removing moderately enlarged nodes. (Dowd.) As regards the operation itself the incisions must be adapted to the location of the diseased nodes. For cosmetic results and also because they tend to fall together and obliterate the dead spaces if made in the natural lines of the skin (Fig. 150), the accompanying illustrations show the favorite methods. A combination of the upper submaxillary incision with a posterior vertical incision has been frequently employed by the writer in cases of extensive disease (Fig. 151). The supra- maxillary branch of the lower division of the seventh in its course below the ramus, the spinal accessory nerve, the muscular branches from the cervical plexus, and the thoracic duct are the main structures that have been cut with disastrous results and must be safeguarded. There is, in the nature of the operation, an extensive cutting of 19 290 INJURIES AND DISEASES OF LYMPHATIC SYSTEM lymph vessels. Accumulations of lymph may occur for two to three days after operation. Some drainage, but only the minimum amount should be instituted. Very small rubber tubes, gutta-percha tissue, twisted silkworm-gut strands are the favorite drains used. A snug, soft dressing reinforced by a starch or an Ideal bandage, though somewhat uncomfortable, is a most efficient method of obliteration of dead spaces and giving rest to the part. When possible, the individual nodes should be enucleated, largely by blunt dissection. When extensive fascial or muscular tuberculosis exists, a most painstaking and careful dissection will be necessary. Fig. 151. — The hockey-stick incision. (Dowd.) Syphilis of the Lymph Nodes. — Enlargement of the lymph nodes occurs during the early stages of syphilis, and requires no treatment other than the- internal and external use of mercury with injections of salvarsan. Gummatous infiltration of the lymphatics, however, may occur late in the disease, and the enlargements thus produced may break down and result in sinuses resembling those caused by tuberculosis, or in extensive syphilitic ulceration of the surrounding skin. As a rule, all of these conditions can be cured by judicious treatment with mercury, potassium iodide, the local use of blue ointment and injections of salvarsan. Occasionally it will be advisable to remove such gummatous tumors which seem about to break down. DISEASES OF LYMPH CHANNELS AND LYMPH NODES 291 Chronic Lymphadenitis, Simple Hyperplasia of the Lymph Nodes, or Benign Lymphadenoma. — These are terms which have been applied to chronic non-snppnrative enlargements, which are apparently not due to tuberculosis, syphilis, or Hodgkin's disease. Such nodes are occasionally associated with chronic otitis media, facial eczema, pediculosis of the scalp, and other sources of irritation or subacute inflammations in the regions drained by their afferent vessels. If such enlargements do not subside after removal of the peripheral irritation, they are in all probability tuberculous in character or due to Hodgkin's disease. Fig. 152. — Early tubercular infection of the deep cervical chain: A, most prominent caseous node; B,B, caseous nodes under sternomastoid muscle; C,C, sternomastoid muscle; D,D,D,D, spinal accessory nerve; E, trapezius muscle; F, levator anguli scapula? muscle; G,G,G, branches of cervical plexus; H, scalenus posticus muscle; /, external jugular vein; K, course of posterior branch of spinal accessory nerve cut from sternomastoid muscle; L, omohyoid muscle; M, internal jugular vein; X, facial vein; 0, posterior facial vein (anterior division of temporomaxillary) ; P, parotid gland. (Dowd.) Malignant Lymphadenoma, or Hodgkin's Disease. — This disease is characterized by a gradual enlargement of the lymph nodes of the body eventually resulting in grave anemia, progressive asthenia, wasting cachexia, and death. The disease begins by a painless enlarge- ment of several lymph nodes, generally on one side of the neck. The glands are discrete, freely movable at first, and show no tendency to suppurate or undergo caseous degeneration. The disease gradually extends and involves the glands on the opposite side, those in the axillae, groins, abdomen, and mediastinum. Later they become fused, often forming enormous irregular masses which cause great disfigurement (Fig. 153). The spleen and other lymphoid tissues enlarge, anemia 292 INJURIES AND DISEASES OF LYMPHATIC SYSTEM and a progressive emaciation occur, and the patients finally die of exhaustion. During the past five or six years considerable discussion has taken place regarding the nature of this disease. It is probably due to a cause of infectious nature, the identification of which has never been made. On microscopical section there is a diffuse hyperplasia of the elements of the node, with a disappearance of the nodules, the appearance of large cells containing three or four or more nuclei, many eosinophiles and often extensive areas of young connective-tissue cells. Fig. 153. — Hodgkin's disease. The disease is one that belongs rather to the domain of internal medicine than to surgery, as operative treatment in the early stages has accomplished little except the removal of deformity and the relief of pressure-symptoms. It is of surgical interest mainly from the point of view of diagnosis, as it at times closely simulates tuberculous adenitis, and at other times is occasionally mistaken for true lympho- sarcoma. The term chronic relapsing fever has been used by Ebstein and others to describe a peculiar symptom-complex which is occasionally observed in these cases. The symptoms of this condition are the occurrence of attacks of high fever and prostration associated with an DISEASES OF LYMPH CHANNELS AND LYMPH NODES 293 enlarged and tender spleen and with moderate swelling and sensitive- ness of one or more lymph nodes of the neck or in other external regions of the body. The attacks occur at intervals of a few weeks or months, gradually becoming more severe, and finally resulting in profound asthenia, wasting, and death. There are no characteristic blood changes in the early attacks, and the condition often resembles a profound septic intoxication. Treatment. — The treatment of Hodgkin's disease is unsatisfactory. The .r-rays will often cause the enlarged nodes to diminish in size for a longer or shorter period. Arsenic in the early stages will often appear to arrest the process temporarily, but progress is inevitable and death always results. Removal of individual nodes is of no avail, and is to be recommended only for purposes of diagnosis, to relieve pressure-symptoms or to overcome deformity. Lymphatic Leukemia. — Lymphatic leukemia is an exhausting and fatal general disease, characterized by profound anemia, an enormous increase in the white corpuscles of the blood, particularly the lympho- cytes, and, at a later period, by enlargement of the lymph nodes of the body. It is easily distinguished from Hodgkin's disease by the blood count. While the disease is invariably fatal in the end, the judicious use of the .r-rays will often bring about a subsidence of all symptoms, and an apparent return to health for a period of two or more years. Lymphosarcoma. — Lymphosarcoma occurs as a primary or a second- ary affection. Primary lymphosarcoma is a highly cellular growth occurring in lymphoid tissue. It is made up of an enormous and rapid growth of cells that closely resemble the lymphoid cells of the nodule, but are slightly larger, and contain nuclei rather vesicular in appearance with distinct chromatin granules and, in rapidly fixed tissues, a great number of mitotic figures. The structure of the nodes is entirely lost and the cells are seen to be infiltrating about the periphery of the node into the surrounding tissues. It occurs in the lymph nodes, in the tonsil, in the lymphoid tissues of the intestines and other organs. It is one of the most malignant varieties of sarcoma. It begins usually as a simple enlargement of a lymph node or of other lymphoid tissue, which grows rapidly and painlessly at first. Later the growth infiltrates surrounding tissues, painful pressure-symptoms are produced and metastases occur. Death often results from pressure on important organs before cachexia has had time to develop. The prognosis is grave. Excepting in the very earliest stages treatment is of no avail. Early and thorough removal is, however, to be recommended as the only chance of saving life. Secondary Sarcoma and Carcinoma. — Secondary sarcoma and car- cinoma of the lymphatics are of frequent occurrence, especially the latter. The nature of these processes has been described, and will not be repeated here. Early and complete removal may occasionally arrest the progress of the growth. CHAPTER XIII. INJURIES AND DISEASES OF THE MUSCLES, TENDONS, FASCLE AND BURS^E. INJURIES OF THE MUSCLES, TENDONS AND FASCLE. Contusions. — The muscles are often severely contused or lacerated and become the seat of more or less extensive extravasations of blood as the result of falls or other injuries which do not break the skin. A fi actuating swelling may develop if the extravasated blood is local- ized, and — although rarely — become infected and converted into an abscess. Ordinarily the extravasation is completely absorbed but occasionally a fibrous scar or cyst may remain. If the overlying fascia is injured ecchymosis develops; otherwise the only symptoms are pain and soreness, both of which are increased by motion and relieved by rest and local applications of heat or lead and opium. Rupture of Muscle or Tendon. — Rupture of a muscle or tendon may occur as a result of severe or sudden contraction, any atrophy or degeneration being a predisposing factor. The injury may occur either at the junction of the muscular and tendinous fibres, through the muscle belly, or at the point of insertion of the tendon, and, except in the latter case, may be accompanied by considerable extravasation of blood. Rupture of the quadriceps extensor, of the tendo Achillis or of the plantaris comprise those most commonly seen. "Lawn tennis leg" is an injury not infrequently seen, the lesion probably involving the gastrocnemius with or without plantaris. "Rider's thigh" is a similar injury to the abductor muscles of the thigh. Diagnosis. — The diagnosis is made by the occurrence of sudden acute pain during a severe muscular effort, occasionally accompanied by an audible snap. There is temporary muscle spasm and pain which is increased by attempted motion. If the rupture is complete the function of the muscle is lost, contraction causing a soft swelling corresponding to the belly of the muscle, without resulting motion in the part to which it is attached. During contraction a depression may be felt at the site of the injury. Considerable extravasation may develop, involving neighboring joints if the injury has extended into the capsule. Treatment. — The treatment depends upon the site of the injury and the extent of loss of function. Slight ruptures are probably best treated by strapping, followed by immediate use of the muscle, thus preventing secondary tearing due to contraction of muscle fibres during repair with the limb immobilized. INJURIES OF THE MUSCLES, TENDONS AND FASCIA 295 If large muscles or tendons are torn more or less completely across with resulting loss of function, as in rupture of the quadriceps or of the tendo Achillis, repair may be affected by rest, approximating the divided ends as well as possible with adhesive plaster. More often, however, operative treatment (myorrhapy) is indicated, the injured parts being freely exposed, blood clots removed, scar tissue removed if the rupture is an old one, and the divided tissues carefully sutured with mattress sutures of chromicized catgut, inserted in layers if the muscle is thick. The part should be immobilized in a position relaxing the injured muscle. The operation should be performed under the strictest aseptic technic, particularly if a joint has to be opened. Hernia of Muscle. — This is a rare condition, following injury or disease, and consists- in the protrusion of muscle fibres through an opening in the capsule. The herniated fibres form a tumor which is largest when the muscle is at rest and disappears on active contraction. This condition is to be differentiated from a false muscular hernia, which is the result of rupture of muscle fibres, the resulting tumor not disappearing when the muscle is contracted, but becoming larger, harder, and moving toward the point of origin of the muscle. Treatment. — The treatment of a true hernia which is causing symp- toms, is operative; the tear in the fascia being closed with catgut sutures, the edges if possible being undermined and overlapped. Occasionally excision of the protruding portion will be necessary. Wounds of Muscles and Tendons. — In these cases the possibility of infection must always be kept in mind, varying considerably with the condition of the patient's skin and the nature of the instrument causing the injury. The surrounding skin should be shaved, and then carefully cleansed, either with soap or tinc- ture of iodine. The wound should, if neces- san% be enlarged so that its depths may be thoroughly exposed and any foreign material removed. This occasionally requires a general anesthetic. Strong chemical disinfectants should not be used because of their harmful effect on tissue, simple cleansing with sterile salt solution usually sufficing. Severe crush- ing injuries require the most careful disinfec- tion, and in these the possibility of infection with tetanus bacilli and the advisability of a prophylactic injection of antitoxin must always be considered. Divided muscles should be repaired with catgut sutures, the fascial layers partly united and the cutaneous wound closed, drain- age being always provided for, either with rubber tubes, gauze packing, rubber tissue or strands of silkworm gut. The extremity should be immobilized. A similar procedure should be undertaken Fig. 154. — Methods of tendon lengthening. 296 INJURIES OF MUSCLES, TENDONS, FASCIA, BURS& when tendons have been divided, bearing in mind the fact that the tendon ends may retract a considerable distance within their sheaths. The ends when found may be sutured with silk or fine ehromicized catgut, changing the position of the limb if necessary so as to bring about the greatest degree of muscular relaxation. Occa- sionally this will not be sufficient to allow approximation without tension, and in this case the tendon may be lengthened in one of various ways, or the ends may be united by long silk sutures which act as a framework into which the tendon gradually grows. Where part of a tendon has been destroyed the lengthening operation may be sufficient for repair, or part of a neighboring tendon of a less important muscle may be taken and grafted to fill the defect. If the distal end of a tendon has been destroyed the proximal end may be sutured into the periosteum as near as possible to the normal site of insertion, the periosteum being split, the tendon end inserted, the periosteum replaced and sutured to the tendon. Tenorrhaphies in which many tendons are involved are long and painstaking operations requiring free exposure and an accurate knowl- edge of anatomy. The ultimate success of an operation depends largely upon the -maintenance of asepsis, infection being often followed by sloughing of tendons. Following suture, the parts should be immob- ilized for two weeks, or longer in the case of grafting operations, to be followed by gradually increasing passive and active motion, accom- panied by massage and baking. Secondary tenorrhaphies following non-repair or attempted but unsuccessful repair of divided tendons are more difficult because of retraction and adhesions. Dislocation of Tendons. — This is a rare condition, occurring usually as a result of trauma or sudden strain. In the majority of the cases reported the peronei have been involved, usually the peroneus longus, the external annular ligament being torn as the tendon comes out of its groove. The diagnosis is made by the sudden onset of localized pain and the recognition of the abnormal position of the tendon. Reduction is usually easy but the dislocation tends to recur. Occasion- ally rest with maintenance of reduction by pads will result in a cure. In other cases the dislocation causes no disability; but if it causes discomfort it may require operation, replacing the tendon and holding it in place by suturing ligament, or if necessary a periosteum and bone flap over the tendon as it passes behind the external malleolus. DISEASES OF THE MUSCLES. Myositis. — Myositis may be either simple or infectious in nature, and occurs as a result of contusions, ruptures or infected wounds, from extension from a neighboring inflammatory process or in septicemia. It occurs also as a part of the pathologic process, in parasitic invasions as trichiniasis. The symptoms in both forms are pain and tenderness, DISEASES OF THE MUSCLES 297 with a stiff, indurated muscle. In the suppurative forms a localized abscess develops later. The non-suppurative variety may be treated by rest and local applications; the suppurative, by incision and drainage. Acute Primary Myositis. — Acute primary myositis is a rather uncom- mon infection, probably due to a staphylococcus, in which the local lesions occur in the muscles, foci of inflammation developing which may resolve or go on to abscess formation with practically complete destruction of muscle fibres. Fulminating cases occur with rapid death from systemic poisoning, while the less severe cases are followed by slow recovery, with atrophy and contraction, as the muscle cells are replaced by fibrous tissue. Myositis Ossificans* — Myositis ossificans is a rare condition, occurring chiefly in young males, in which there is a development of bone tissue in the muscles accompanied by atrophy of muscle fibres, the patient gradually becoming more and more helpless. There is no curative treatment. This condition should not be confused with myositis ossificans traumatica, a condition in which as a result of repeated trauma new bone forms in a muscle, usually at its point of attachment to the peritoneum. This may also occur following a single trauma such as a fracture, osteogenetic cells being displaced outward into the muscle tissue. If these bony masses cause symptoms they should be removed. Tuberculosis. — This usually occurs by direct extension from neigh- boring foci and results either in abscess or, if the tissues are more resistant, in sclerosis. Metastatic tuberculosis of muscles is very rare, usually follows trauma and may go on to the formation of cold abscess. The diagnosis is made largely by exclusion, or the finding of tuberculous lesions in other parts of the body in a non-syphilitic patient with a history of slight muscular pain and disability, examina- tion showing a mass in the muscle tissue. When possible, in a case of this sort, excision is indicated before the disease has extended beyond one muscle. Syphilis. — Syphilis of muscles occurs in the tertiary stage as a diffuse sclerosis or localized gumma, both leading to contractions and deformity. The sternomastoids and the muscles of the tongue are most often involved. Gummata may be mistaken for sarcoma, the diagnosis resting on the results of treatment. Atrophy. — This may be simple or combined with fatty or amyloid degeneration. It occurs as a result of disease, following myositis and after injuries to, or diseases of, the motor nerves. The atrophic muscles are usually soft and flabby, occasionally sclerosed, and are frequently accompanied by deformities due to the unopposed actions of the remaining healthy groups of muscles. New Growths of Muscles. — New growths of muscles are rare as pri- mary conditions but any of those of mesoblastic origin may occur. Secondary growths are more common, following carcinoma or sarcoma. Fibromata of the rectus abdominis, occurring most frequently in 298 INJURIES OF MUSCLES, TENDONS, FASCIA, BURSA women who have borne children are known as desmoids. The treat- ment of new growths of muscles should be governed by the same principles that apply to new growths of other tissues. DISEASES OF THE TENDONS. Tenosynovitis. — Inflammation of the tendon sheaths has been taken up in the section on Infections of the Hand and Fingers, page 222. Tumor of Tendon Sheaths. — Any of the connective-tissue tumors may occur, growing either on the inner or outer side of the sheath. The diagnosis from tuberculosis may be difficult. The treatment in all cases is excision. ^^ Fig. 155. — Ganglion of the wrist. Ganglion. — Ganglia are small cystic tumors usually found on the dorsal surface of the wrist, occasionally on the flexor surface near the metacarpophalangeal joint, rarely on the dorsum of the foot. They occur as a rule in young individuals, often apparently following strain or an unusual use of the hand or arm. At one time they were thought to be hernial protrusions from joints or tendon sheaths, but the work of William C. Clarke and others has shown that they are the result of degenerative processes in the connective tissue about the joints or tendon sheaths, collagenous degeneration being followed by the de- velopment of thin-walled cysts containing clear serous or gelatinous fluid. Secondary communication with the joint cavities or tendon sheaths may develop. Ganglia rarely cause pain but occasionally patients complain of a sense of weakness in the affected part. DISEASES OF THE FASCU2 299 Treatment. — Small ganglia causing no symptoms may be dis- regarded. Occasionally a cure may be obtained by a subcutaneous rupture of the ganglion by means of a blow with some heavy blunt instrument, or the cyst may be punctured with a tenotome. Either form of treatment should be followed by firm pressure, with a pad and bandage, and both are frequently followed by recurrence. The most successful treatment consists in excision under strict aseptic precau- tions, as the joint or tendon sheath may be opened. Compound palmar ganglion is the term applied to a distended con- dition of the sheath of the flexor tendons of the fingers due to a chronic tenosynovitis, usually tuberculous in nature. DISEASES OF THE FASCIA. Fascial Tuberculosis. — While extension of tuberculous process to the fasciae and muscles surrounding a given focus is often seen, fascial tuberculosis may also occur practically as an independent disease, arising from an insignificant glandular focus and continuing the chief factor in a given case. It occurs chiefly in the neck, axilla, groin and retroperitoneal tissues and is characterized as a slowly progressing inflammatory process with thickening and induration of the fascia and intermuscular septa. Pain is rarely prominent, but rigidity may be present. The process may remain latent or break down and suppurate, leaving persistent sinuses. Treatment. — The treatment should consist in thorough operative removal of the diseased tissue. Occasionally Beck's paste or formalin and glycerin (2 per cent.) may be used successfully in the treatment of sinuses where operation is contra-indicated. Dupuytren's Contraction. — Dupuytren's contraction is a condition of permanent flexion of one or more fingers due to a chronic thickening and contraction of the palmar fascia, involving especially the longitu- dinal fibres extending from the palm to the tendon sheaths of the fingers. Microscopically it consists in the general formation of a dense scar involving the fascia and the adjacent connective tissue and extend- ing to the joint and tendons. It is more common in men over middle age, and while little is known as to the etiology, it has been ascribed to trauma, gout, rheumatism, arteriosclerosis, syphilis and organic nervous disease. Symptoms. — The earliest symptoms are the appearance of small lumps in the palm followed by general loss of extension of the affected fingers which are most often the fourth and fifth. As the contraction of the fascia advances the finger is flexed more and more sharply until the tip may come to rest against the palm of the hand (Fig. 156) . The thickened fascia can easily be felt and made more tense by attempts to extend the fingers. At first the skin is movable over the fascia but later becomes adherent, wrinkling as the finger 300 IX JURIES OF MUSCLES, TEXDOXS, FASCLE, BURSA is moved. The condition is progressive, causing increasing deformity and loss of function and is often bilateral, although generally more advanced on one side than on the other. Treatment. — In the early stages attempts may be made to stop the progress of the disease by massage and the use of splints, but as a rule operative treatment is necessary. This may consist of subcutaneous or open division of the bands, or better, of complete excision of the contracted tissue through longitudinal incisions. In some cases it has been suggested that the skin of the palm and the entire palmar fascia be removed and the defect filled by a graft from the chest or thigh. Fig. 156. — Dupuytren's contracture. INJURIES AND DISEASES OF THE BURSA. The bursa? are sacs lined by synovial membrane located at points where there is constant or intermittent pressure on bone, either through the action of tendons or through external agencies. Bursa? exist normally in certain situations, as over the patella or olecranon, and elsewhere develop as the result of long-continued pressure or irritation, the former being spoken of as anatomic and the latter as adventitious bursa?. Some of the bursa? normally communicate with the adjacent joint cavity, others occasionally do so, while the majority are wholly independent of joints or other synovial sacs. Contusions. — These are the result of trauma and usually result in a hematoma which occasionally breaks down. Over bony prominences, such as the patella or olecranon, they may make the diagnosis of a fracture a difficult one. The symptoms and treatment are similar to those of hematomata elsewhere in the soft parts. Acute Bursitis. — This may arise following trauma, rheumatism, gonorrhea or direct infection through a wound. The symptoms INJURIES AND DISEASES OF THE BCRS.E 301 are those of a localized inflammatory process, and in the simple will subside with rest and wet applications. The suppurative variety requires incisioo and drainage, with occasional secondary operations to destroy persisting secreting tissue. Chronic Bursitis. — Chronic bursitis may arise from the same causes as the acute condition, in the majority of cases following mild but long- continued trauma. Tuberculosis is the cause in a certain number of cases. In the traumatic cases the fibrous capsule becomes thickened and an excessive amount of fluid is secreted, distending the sac and forming a globular swelling. In tuberculosis one of two conditions may predominate. In one the capsule is thickened and on section presents from within cut ward fibrin, tuberculous granulations and dense fibrous tissue: The granulation tissue may be excessive in amount, forming a doughy swelling and i- prone to caseate and form a cold abscess. In other cases the fluid is more prominent, and occasion- ally coagulates to form rice bodies. Syphilitic bursitis is uncommon, usually occurs in the tertiary stage, forming a more or less uodular swelling of the diseased bursa which i- most often the patellar. In the majority of cases there i> little pain in chronic bursitis, the symptoms being -imply the presence of a globular fluctuating swelling over the site of the bursa with more or less stiffness and los> of function. The differential diagnosis between tuberculous and non-tuberculous bursitis may be very difficult. Pain may or may not he a prominent symptom, depending largely upon the situation of the bursa and the resulting amount of pressure to which it i- subjected. Treatment. — The treatment of chronic bursitis in general con^t- in removal of the cause of inflammation and either conservative or operative treatment of the bursa itself. The former comprises the various forms of counter-irritation, of which the actual cautery is the most efficacious. Among the operative mea-ures are puncture, followed by pressure, with or without irritation of the sac wall by carbolic acid or the tip of a trocar; incision and packing; and complete excision. When feasible the latter is the best form of operative treatment, especially if there is any possibility of tuberculosis. Subdeltoid or subacromial bursitis is one of the most common forms of bursitis and one of the most frequent pathological conditions about the shoulder-joint. Codman has made it a much more easily recognized condition, as in the past the diagnosis often has been confused with chronic arthritis, neuritis, [muscular rheumatism, contusion of the shoulder, etc. The disease is generally traumatic and has been divided by Cod- man into three types: acute or spasmodic; subacute or adherent, chronic or non-adherent. In all the types the symptoms are pain, usually referred to the insertion of the deltoid and more severe at night, accompanied by tenderness below the tip of the acromion to the outer side of the bicipital groove, inability to abduct the arm through an arc of more than ten degrees if the scapula is immobilized, 302 INJURIES OF MUSCLES, TENDONS, FASCIA, BURSM and by pain on attempted external rotation. When the arm is abducted above the head, tenderness may disappear, the bursa passing upwards beneath the acromion out of reach of the examining finger. Stiffness and limitation of motion become more marked as the condition becomes more chronic, motion being limited by adhesions rather than by spasm, as in the acute stages. In the chronic stage without adhesions motion may be comparatively free but painful in certain directions. Treatment. — In the acute stage treatment should consist in rest with the arm abducted. Prolonged immobilization, however, will tend to the formation of adhesions, so that this method of treatment should not be too long continued. As the acute symptoms subside, baking, massage, and active and passive motion may be begun. Cauter- ization often gives relief from pain and improves function. Occasion- ally forced motion under anesthesia with the object of rupturing adhesions may be tried but adhesions broken in this way are very likely to reform. Incision of the bursa with division of the bands, as suggested by Codman, is the preferable procedure. Codman has reported a few cases in which symptoms of subacromial bursitis have been simulated or caused by rupture of the supraspinatus tendon, with good results following operation. Albert's Disease. — Albert's disease or inflammation of the bursa beneath the Achilles tendon is a condition causing pain in walking, especially when the weight of the body is raised on the toes. The bursa may be felt as a tender swelling above the attachment of the tendon to the os calcis. It i? often confused with an inflammatory condition of the tendon itself {tendinitis Achilla traumatica) which may follow prolonged walking, bicycle riding, etc. Bunions. — Inflammation in the bursa over the metatarsophalangeal joint of the great toe follow ill-fitting shoes and are secondary to the bony deformity (hallux valgus) the bursa being an adventitious one. Inflammation of the bursa about the hip and knee-joints are often the cause of symptoms simulating joint disease, and in many cases are followed by or associated with an arthritis. Various bursa? such as the olecranon, prepatellar or ischial are frequently found inflamed in certain occupations, and to these names such as "housemaid's knee," "miner's elbow," etc., have been given, the whole group being classed together as trade bursitis. Treatment. — The treatment of these conditions during the acute stage consists in rest and cold applications, with counter-irritation, and if necessary, excision when the chronic stage is reached. Tumors of Bursas. — These are very rare conditions, only a few having been reported, all of the connective-tissue types. They should be excised. CHAPTER XIV. INJURIES AND DISEASES OF THE NERVES. INJURIES OF THE NERVES. Contusions. — A nerve trunk may be contused as a result of a blow, a fall, or any other trauma, but such injuries are rare from the fact that, as a rule, the nerves are so situated as to be protected from external violence. The nerves most exposed to such injuries are the ulnar at the elbow, the cords of the brachial plexus, the facial, the sciatic, the external popliteal, and the anterior tibial. In many instances the nerve lesion is associated with a fracture or dislocation. Symptoms. — The symptoms of contusion of a nerve trunk are pain, a feeling of tingling, numbness, or the sensation of pins and needles in the region supplied by its sensory branches, with weakness or paralysis of the muscles. The symptoms are generally temporary unless the injury gives rise to a neuritis or degeneration of the nerve fibres. Treatment. — Treatment other than rest is rarely necessary for this condition. If, however, there is delay in restoration of function, counter-irritation over the injured area, massage, and electricity to the region of its distribution are to be employed. Wounds of Nerve trunks. — These injuries are of fairly common occurrence. They are caused by fractures, accidents with knives or other sharp instruments, cuts from glass, gunshot wounds, and, not infrequently, accidental division takes place during surgical operations. As a result of such injury a nerve trunk may be completely divided or it may be simply lacerated. When a nerve trunk is completely divided, certain changes occur in its peripheral portion, beginning on the second or third day and continuing for three or four weeks. These changes are in the nature of a degeneration, and consist in a gradual destruction of the myeline and the axis-cylinders. This causes atrophy of the nerve and degenerative changes in the muscles supplied by it. These changes are recognized by the " reaction of degeneration" in the affected muscles, which is indicated by certain alterations in the reaction of the muscles to the electric currents, the chief change being a failure of the muscle to respond to the faradic, and occasionally an exaggerated response to the galvanic current. The proximal end of a divided nerve trunk becomes gradually thickened and presents a bulbed extremity, made up of connective tissue and coiled axis- cvlinders. Occasionallv in uninfected wounds when the ends of a 304 INJURIES AND DISEASES OF THE NERVES divided nerve are separated by a short interval only, repair will take place with more or less complete restoration of function, as evidenced by a return of sensation after neurotomy or even neurectomy for neuralgia. Repair, however, takes place much more often and in a far more satisfactory manner if the divided ends are early approximated by open operation and suture. This regeneration of injured or divided nerves is a most important surgical fact, and the nature of the process has been extensively studied. All observers agree that it is possible only in the peripheral nerves, and is due to the presence of the neurilemma. Considerable difference of opinion exists regarding the nature of the process, many holding that the new axis-cylinders develop wholly in the central trunk and pass downward in the sheath of the peripheral portion, which acts as a scaffolding or conduit for their transmission. Other observers believe that new axis-cylinders develop in the peripheral portion of the divided nerve from a prolifera- tion of the neurilemma cells, but that these axis-cylinders remain immature and functionless until they unite with the axis-cylinders of the central end of the nerve, when regeneration becomes complete. All agree, however, that the condition necessary to a restoration of function is early and accurate coaptation of the divided ends. Symptoms. — The symptoms of complete division of a nerve trunk are total paralysis of the muscles supplied by it, and if it be a mixed nerve, anesthesia over the region supplied by its sensory fibres. The anesthesia is generally incomplete and its exact limits difficult to determine, owing to a mixed nerve supply in most cutaneous areas, and also to the fact that a region of total anesthesia when present is apt to be surrounded by a zone of diminished sensibility. The reaction of degeneration is to be looked for in motor nerves. Certain trophic disturbances follow the division of a nerve, generally some time after the accident. These consist first in hyperemia over the region of its distribution, which later is succeeded by anemia of the part. The skin becomes shiny, and atrophied (glossy skin); the nails are roughened, present furrows, and crack; the hairs drop out or lose their color and lustre; and there may develop an extreme burning sensation which causes great suffering. If the injury to the nerve is simply a wound or laceration without complete division, the symptoms may be those of a contusion with more or less sensory and motor paralysis, generally associated with considerable pain at the point of injury and extending over the course of the nerve. Incomplete division of a nerve with continued irritation of the wounded portion, as from a contracting cicatrix, is apt to be followed by an exaggerated degree of pain and trophic disturbance. Treatment. — Whenever an important nerve trunk has been divided, the treatment should be union of the divided ends by suture at the earliest possible moment, as restoration of function depends in great measure upon the promptness with which the reparative processes IS JURIES OF THE NERVES 305 are inaugurated. Doubtless much improvement often follows late secondary operations, but in these cases the improvement is apt to be greater in the sensory or trophic disturbances; the degenerated muscles later give evidence of restoration of function but not, as a rule, as great as that of sensation. In recent injuries the parts should be rendered aseptic by the usual methods, the wound sufficiently enlarged to give a satisfactory exposure of the divided nerve, which should be brought together and held by one or more catgut or fine silk sutures. If the ends are widely separated, they should be well drawn out and stretched sufficiently to allow easy approximation without tension. This is always possible in fresh wounds in which there has been no loss of tissue. After the nerve has been sutured it should be covered by a layer of muscle, fascia or fat, to prevent cicatricial tissue forming about the line of union, and the wound closed with a view to primary healing. The success of the operation depends very largely upon the absence of infection. If the suture has been success- ful, an improvement in the trophic symptoms will be first observed, later a gradual return of sensation. The sensation at first will be abnormal in charac- ter, as a tingling or burning in the extremity, followed by a gradual progress toward the normal. Motion returns later, and may not be complete for many months. If considerable time has elapsed since the injury, and the primary wound has healed, it is still desirable to expose and suture the nerve, although the result will probably be less perfect than in operations undertaken at an earlier period. An incision should be made over the anatomic line of the nerve, and its divided ends located, separated from the surrounding adhesions, and drawn toward each other. The bulbed extremities are to be excised and the ends approximated, as in the earlier operation. If the ends cannot be brought together without tension, the incision should be extended, and a further attempt made to stretch the nerve, both from above and below. If this succeeds, a retention suture of chromicized catgut should be introduced above and below, from one- quarter to one-third of an inch from the divided ends, and drawn tightly enough to bring the ends in easy apposition; they should then be united with two or three fine catgut or silk sutures, preferably passed only through the sheath (Fig. 157) . If coaptation is impossible, 20 Fig. 157. — Methods of nerve suturing: A, B, sutures passing through sheath and part of nerve; C, sutures through sheath, reinforced by relaxation suture through entire nerve. 30G IX. JURIES AND DISEASES OF THE NERVES the nerve may be grafted by the insertion of a section of nerve from a freshly killed rabbit or dog, or one removed from a recently ampu- tated limb; or the nerve may be lengthened by flaps cut from the upper and lower portions and united as in tendon suture (Fig. 158). Passing numerous strands of catgut between the divided ends by means of a fine curved needle has been recommended, also enclosing the strands within a tube of decalcified bone or a small section of a formalinized artery which also surrounds the nerve for a short distance above and below. In all of these plans the intermediary substances simply serve as conductors of the new axis-cylinders, and afford protection against the formation of scar tissue between the divided ends of the nerve. That these are the essential elements in successful nerve suture is evidenced by the experiments of Forsman, who found that if he placed the divided ends of a nerve in a straw tube regeneration took place, but was slow. If, however, the ends of the nerve were connected by a thread, or the lumen of the straw filled with brain substance, the repair was far more rapid. After healing of the operative wound the affected region should be treated by massage, hot and cold douches, and electricity. The Fig. 158. — Nerve suture with lengthening. judicious use of these measures will often retard degenerative changes in the muscles. Compression of Nerve trunks. — Permanent compression of a nerve trunk is generally caused by contraction of a cicatrix, pressure of a displaced bone or callus following dislocation or fracture, or to growth of a tumor or aneurism. The symptoms are variable. There may be simply the numbness and muscular weakness of a contusion, or the impairment of function may progress until total paralysis of sensation and motion occurs. Pain is often a prominent symptom. The treatment should consist in removal of the cause of the pressure. Dissecting the nerve free from an encircling cicatrix or mass of callus, or the removal of fragments of bone or a neighboring tumor, will often bring about a permanent cure, although a return of sensation and motion may be delayed, as after more severe injuries. Among the most frequently observed traumatic palsies are those of the facial muscles due to injury to the seventh nerve from fracture at the base of the skull, those of the extensor muscles of the forearm due to pressure on the musculospiral nerve, from fracture of the humerus, ulnar paralyses from fractures of the internal condyle of the humerus, and paralyses of the leg muscles from fractures about the knee-joint, causing pressure on the popliteal nerves. DISEASES OF THE NERVES 307 DISEASES OF THE NERVES. Neuritis. — Neuritis is an inflammation of the sheath of a nerve trunk and of the connective tissue between its fasciculi. It arises from a variety of causes, some of which are not well understood. Trauma, wound infection, pressure, general sepsis, the infectious diseases, gout, rheumatism, alcoholism, lead poisoning, and other chronic toxemias are generally enumerated among the causes of this condition. The disease may be limited to a single trunk, or a very large number of nerves may be affected, giving rise to a serious condition known as multijjlc neuritis. In the former there is generally present well-marked thickening and edema of the trunk, in the latter, chiefly degenerative changes. Symptoms. — The symptoms of neuritis vary with the cause of the disease and the acuteness of the attack. A neuritis following an acute trauma or due to extension of a septic process to the tissues of the nerve, may give rise to severe pain radiating over the area of distribu- tion of the nerve, with localized tenderness, and to the presence of a hard tender cord if the nerve is superficially located. In less acute cases the symptoms may be simply a numbness or the sensation of pins and needles over the affected area, followed by a gradually develop- ing anesthesia with trophic disturbance. In motor nerves there will be muscular paresis or paralysis, often with atrophy and the reaction of degeneration. In certain eases of acute neuritis the process is an ascending one, and may eventually involve a plexus or the spinal cord. When the inflammation reaches the plexus, symptoms will appear in the other branches of distribution; when the cord becomes involved, symptoms of myelitis are present. Treatment. — The treatment of neuritis is almost entirely medical, and should consist in absolute rest of the part if the pain is severe, with counter-irritation over the course of the nerve. Later the use of massage, baths, and electricity is to be recommended to favor the processes of repair and to prevent wasting of the muscles. Con- stitutional conditions, as gout, rheumatism, or syphilis, shculd receive appropriate treatment. If sepsis or pressure is found to be an etiologic factor, it should be removed surgically. Another surgical measure which is frequently of benefit in chronic cases, especially where trophic ulcerations are present, is nerve-stretching. It is desirable to pre- vent secondary muscular contractions by the use of splints or other mechanical apparatus. Neuralgia. — Neuralgia is a condition characterized by severe radiat- ing pain following the course of a sensory or mixed nerve, unaccom- panied by evidences of inflammation or systemic disturbance. The pain may be continuous or intermittent. When intermittent, the paroxysms may occur as often as every two or three minutes, or the intervals may be prolonged to several hours or days. Each paroxysm may be characterized by a sudden, acute, darting pain, which may 308 INJURIES AND DISEASES OF THE NERVES be the cause of convulsive movements in the neighboring muscles (especially in neuralgia of the fifth nerve), and may as suddenly cease; or the pain may begin with a slight discomfort which gradually increases in severity until the most acute suffering is produced, and then suddenly or gradually subsides. Patients suffering from neu- ralgia may have a series of attacks extending over a period of several days or weeks and then be free for a number of months. Etiology. — The causes of neuralgia are obscure. Apparently it is often due to malaria, rheumatism, gout, syphilis, or lead poisoning, but quite as often it occurs without association with any of these toxemic conditions. General ill-health from any cause, and especially anemia, seem often to be associated with neuralgia. Of the local causes, trauma, irritation of one of the peripheral branches of a nerve, pressure from any cause, and exposure to cold and dampness, are the most frequent. Faulty nutrition of a nerve trunk or ganglion from an obliterating endarteritis of the minute vessels of the sheath not infrequently leads to degenerative changes which may account for the impaired function of the nerve. This has been observed particularly in the Gasserian ganglion in severe cases of tic douloureux. Diagnosis. — In the diagnosis of neuralgia one should remember that much confusion has arisen by the careless manner in which the terms neuralgia and neuritis have been used. While both con- ditions give rise often to chronic pain over the distribution of certain sensory or mixed nerves, one should limit the term neuritis to those cases in which some gross evidence of an inflammatory process is present, as tenderness or thickening over the course of the nerve, more or less continuous pain, aching or discomfort, muscular weakness, trophic disturbance, or evidence of degeneration. In pure neuralgia none of these symptoms are present, the pain is sharp, stabbing, and paroxysmal, with intervals of complete freedom from abnormal sensations. Pressure over a nerve which is the seat of neuralgia will often give a certain measure of relief, while the same pressure over the nerve in a case of neuritis will increase the suffering. It must be admitted, however, that in certain cases both conditions seem to be associated. Treatment. — In the majority of instances the treatment of neuralgia falls to the care of the physician rather than the surgeon. Iron, quinine, salicin, cod-liver oil, and good food, associated with the local use of heat, menthol, or other soothing applications, will be found useful in the treatment of most cases in which the cause is obscure Large doses of aconite or strychnine have been advised, and hydro- therapy or a change of climate will often be of great benefit. For the immediate relief of pain the use of aspirin, phenacetine, acetanilid, or some of the other coal-tar analgesics, or opium in some form, is frequently necessary. Galvanism is often effectual. When these measures are unsuccessful and the suffering is great, surgical inter- vention is indicated. Neuralgia is treated surgically by the removal DISEASES OF THE NERVES 309 of a direct cause, as the pressure of a tumor, cicatrix, or foreign body upon the nerve; or by the removal of a reflex cause, as the treatment of carious teeth, intranasal conditions, disease of the accessory sinuses, or of ovarian, renal, rectal, vesical, or urethral sources of irritation; by nerve-stretching in neuralgia of a mixed nerve; by neurotomy, neurectomy, or the injection of alcohol, osmic acid, or other chemical substances into the nerve trunk with a view to producing degenerative changes, in disease of a purely sensory nerve. Nerve-stretching. — This is applicable to disease of any accessible nerve-trunk, but is employed most frequently in sciatica. The nerve should be exposed by an incision, carefully separated from the neighboring tissues, surrounded by the bent finger, a strand of gauze, or a blunt hook, and progressively increasing traction made for four or five minutes, after which the wound is closed and an aseptic dressing applied. Temporary improvement almost always follows this procedure, and permanent relief is sometimes obtained. The sciatic nerve may also be stretched by the dry method, by placing the patient on his back and forcibly flexing the thigh on the body, the leg being held in complete extension. Roman von Baracz, in a recent article, asserts that in obstinate cases of sciatica adhesions frequently exist between the trunk of the nerve and the tissues at or just within the sciatic notch, and advises exposing the nerve at this point and separating the adhesions with the finger. Bennet and Niordano have successfully resected the posterior roots of the nerve in rebellious sciatica. Neurotomy and neurectomy have been largely employed in the treatment of neuralgia. Division of a nerve-trunk gives instant relief to neuralgic pains in its branches, but recurrences are frequent after this operation, due to a subsequent union of the divided ends. Removal of a section of a nerve-trunk, leaving a considerable interval between the divided ends, which may be filled with sterilized paraffin, rubber tissue, or some other unirritating substance, is more successful, but the symptoms recur not infrequently after these procedures. Tic Douloureux. — Of all the different forms of neuralgia, the cases most likely to fall to the care of the general surgeon are those affecting the various branches of the fifth cranial nerve, and grouped under the term tic douloureux. If the disease is limited to one of the three divisions of the nerve, neurotomy, neurectomy, or alcohol injection may be practised. Of these procedures, the last two only are to be recommended. If the disease affects all three divisions of the nerve, or if the disease has resisted all other rational methods of treatment, and the symptoms are so severe as to warrant the patient assuming a considerable risk to obtain relief, intracranial neurectomy or removal of the Gasserian ganglion is to be recommended. Neurectomy of the First Division of the Fifth Nerve. — The supra- orbital nerve is exposed by a horizontal incision just below the superior margin of the orbit, dividing the tissues down to the supra-orbital 310 INJURIES AND DISEASES OF THE NERVES notch, through which the nerve passes. The nerve is then grasped by an artery-clamp and separated from the surrounding orbital fat, which is depressed by a flat retractor. Traction is then made upon the nerve until the supratrochlear branch is exposed. The nerve is divided behind this branch and the peripheral portion removed. The wound is then closed and an aseptic dressing applied. Neurectomy of the Second Division. — Expose the infra-orbital nerve by a curved horizontal incision along the lower margin of the orbit. The nerve will be found passing out of the infra-orbital foramen lying on the levator labii superioris muscle. It should be grasped with an artery-clamp or a piece of stout silk tied around it. The orbital periosteum and fat should be retracted and the canal broken open by a chisel, the nerve drawn outward, divided as far back as possible, and the peripheral portion removed, after which the wound should be united and dressed. A far more complete but more difficult operation is that suggested by Carnochan. Expose the infra-orbital region by a T-incision, the perpendicular arm extending from the infra-orbital notch to a point near the angle of the mouth, the horizontal arm along the inferior margin of the orbit. Next, isolate the nerve as it emerges from the foramen and secure it with a piece of strong silk; then divide all tissues down to the bone and arrest bleeding. Next remove a portion of the anterior wall of the antrum with a chisel or trephine, and then remove a small button from the posterior wall with a one-half inch trephine, exposing the sphenomaxillary fossa. The infra-orbital canal is then opened from below by a chisel or bone-forceps, throughout its entire length, after which the nerve is drawn downward into the trephine-opening through the posterior wall of the antrum, and followed backward to the foramen rotundum. It should be divided as near the foramen as possible, and the entire extracranial portion removed, including the sphenopalatine or Meckel's ganglion. Considerable venous hemorrhage will accompany the manipulations in the spheno- maxillary fossa, which is best controlled by packing. The packing may be allowed to remain in place two or three days, and after its removal the cutaneous wound can be sutured without anesthesia, as all sensation in the part has been abolished by the operation. Neurectomy of the Third Division. — Make a curved incision around the angle of the jaw, dividing only the skin and superficial fascia; isolate the two main branches of the facial nerve and Stenson's duct, which lie on the fascia covering the masseter muscle, retract these structures and separate the fibres of the masseter muscle, exposing the ascending ramus of the jaw. Next trephine this just above the angle and locate the nerve as it enters the dental canal. Divide it as close to the canal as possible, grasp the proximal end with forceps, and follow it upward for an inch or more, and divide with blunt scissors. Unite the cutaneous incision and apply an aseptic dressing. As recurrences after these peripheral neurectomies were of frequent occurrence, Thiersch, in 1889, advocated a more thorough removal DISEASES OF THE NERVES 311 of the nerve trunk by evulsion. His method consisted in exposing the nerve by the usual method, seizing it with a pair of forceps, and, by a slow twisting motion, to evulse both the central and peripheral portions. Moschcowitz has recently reviewed the subject, and has demon- strated by personal observation and by referring to numerous reports of others, both clinical and experimental, that the cause of a recurrence of the symptoms after all peripheral operations is a regeneration of the nerve, which can be demonstrated by a re-exposure of the site of the original operation. He logically concludes that the only method of preventing a recurrence is to introduce an effective barrier to the passage of the newly developed nerve fibres through the bony canal. For this purpose he. suggests the use of blunt-pointed silver tacks, which can be firmly driven into the various foramina, or of silver foil or dentist's amalgam, with which a bony canal can be plugged. The Injection Methods. — The injection into a bony nerve canal or, still better, into the nerve trunk of 1 c.c. of a 1 per cent, solution of osmic acid has been followed by relief in many cases as reported by Bennett, Murphy, and others. The method consists in exposing the nerve at the foramen of exit and injecting the solution by means of a hypodermic syringe. The contact of the acid blackens the tissues, and for that reason the surrounding skin should be protected. The injection of 80 per cent, alcohol into and about the nerve trunks has recently been advocated by Schlosser and others. The results which have followed this method have been encouraging. Kiliani has reported 55 personal cases, of which 47 were definitely relieved. He makes no claim to permanency of result, but suggests that recur- rences can be easily treated in the same manner. The injections are made by means of a syringe and a long, blunt, or acutely bevelled needle. No anesthesia is required, and, by a reasonable degree of anatomic knowledge and skill all of the peripheral foramina and even the rotundum and ovale can be reached. About 1.5 c.c. of 80 per cent, alcohol, with or without the addition of a small amount of cocaine, is injected into the foramen. If successful, the injection should immediately be followed by a burning pain over the area of distribution of the nerve, later by numbness and anesthesia. When all peripheral methods fail, or in cases of severe neuralgia, involving two or all three branches of the nerve, one of the intracranial methods is to be recommended. Three operations are to be considered : Removal of the Gasserian ganglion, division of its sensory root, or section of the second and third branches with the interposition of a folded strip of rubber protective tissue or some other substance to prevent regeneration. Intracranial Neurectomy or Removal of the Gasserian Ganglion. — The Gasserian ganglion may be exposed by the Hartley-Krause operation. Make an omega-shaped incision extending from the anterior extremity of the zygoma upward and backward along the 312 INJURIES AND DISEASES OF THE NERVES temporal ridge to its posterior extremity (Fig. 159). Carry the incision down to the skull, arrest hemorrhage, and divide the bone in the line of this incision, using a surgical engine, or the Gigli saw through several small trephine-openings, care being taken not to wound the dura. The flap, consisting of the bone adherent to the soft parts, is then raised with periosteal elevators and broken off along the line of its base, which should be just opposite the zygoma. The middle meningeal artery may be injured by separating the bone from the dura and should be secured by a fine silk ligature passed beneath the dura with a small curved needle. The lower margin of the opening into the skull may be extended by removal of the thin plate of bone with rongeur forceps. When all hemorrhage is arrested and the position of the head is so adjusted as to admit the greatest amount of Fig. 159. — Osteoplastic flap turned down, exposing the dura mater and middle meningeal artery. The brain and dura are then pushed upward so as to expose the petrous bone with the ganglion lying on its apex. (Hartley.) light, the dura is very slowly and very gently raised from the middle fossa of the skull by the fingers or a smooth gauze sponge, until the foramina (rotundum and ovale) are exposed. When these are freely exposed, the dura and brain are well retracted by means of a flat highly polished spatula, and the second and third divisions of the nerve drawn upward on a small blunt hook and divided as close to the bone as possible. The proximal portions of the two nerves are then secured by two artery-clamps, the dura divided between the nerves along the thin curved edge, made prominent by upward traction on the clamps, and the sheath of the ganglion opened. The ganglion is removed by twisting the two clamps so as to tear the branches and the attached ganglion backward away from the untouched first division. The difficulties of this operation are chiefly from severe and long-continued DISEASES OF THE NERVES 313 venous hemorrhage from small and large dural trunks emptying into the cavernous sinus or from a wound of the sinus itself. This generally can be controlled by gauze packing, irrigating the wound with hot salt solution, or both combined. The operator should be provided with a large number of conveniently sized strips of gauze, which may be used for packing the apex of the wound, allowed to remain a minute or two and then removed. Raising the patient to the sitting posture and the application of adrenalin to the bleeding point, will sometimes be of service. After removal of the ganglion and arrest of the hemor- rhage the bone-flap should be replaced and secured with silkworm- gut sutures, a small rubber tissue drain being left in one angle of the wound. The eye should be protected by a small layer of sterile cotton covered by several layers of gauze, the wound dressed, and the whole held in place by a snug head bandage of starched crinoline. Harvey W. Cushing exposes the ganglion by a lower incision simi- larly curved. The temporal muscle and zygoma are divided in the line of the incision, and both are turned downward, exposing the lower portion of the temporal fossa of the skull. This is broken through with a chisel and the opening enlarged with the rongeur forceps. The dura with the middle meningeal artery is gently retracted and the ganglion exposed, as in the Hartley operation. The advan- tages of this route are that there is little or no risk of wounding the middle meningeal artery, and as the opening in the skull is nearer the ganglion, its exposure can be accomplished with a minimum amount of retraction and compression of the brain (Fig. 160). By means of this incision one is also able to expose the second and third divisions as they emerge from their foramina, and thus perform an extracranial neurectomy. Spiller and Frazier, in 1901, suggested as a substitute for complete removal of the ganglion simply section of the posterior sensory root. The ganglion is exposed by the Hartley or Cushing method, the foramen ovale recognized, and an incision made in the dura from the foramen backward over the sensory root, great care being taken to avoid wounding the middle meningeal artery as it emerges from the foramen spinosum. The dura is next stripped from the posterior portion of the ganglion and the sensory root until the latter is sufficiently exposed to enable the operator to surround it with a blunt hook. The root is then drawn forward and divided, evulsed, or a small portion resected. The wound is then closed, as described above, and an aseptic dressing applied. Cushing has recently adopted this method, and believes, with Frazier, that the procedure is quicker, safer, and as effectual as removal of the entire ganglion. Frazier states that it is possible in most of these cases to avoid division of the motor root. A still less hazardous operation is the one described by Abbe in the Annals of Surgery, Jan., 1903. It consists in exposing the ganglion, severing the second and third divisions, and preventing reunion by 314 INJURIES AND DISEASES OF THE NERVES placing a folded piece of rubber protective tissue over the foramina. This, in cases in which the neuralgia is limited to the second and third divisions of the nerve, is often effectual. Mixter introduces dentists' amalgam into the foramina, and is strong in his endorse- ment of the procedure. ■JVXjrt* ^tt\.t;*wvjw^.mB^«„ K^< Fig. 160. — Showing relations of the middle meningeal artery to the operative foramen before and after elevation of the dura and exposure of the ganglion. (Cushing.) In exposing the ganglion for any of these procedures, if the Cushing method is used, some embarrassment occasionally will be encountered by the presence of an elevated ridge of bone just external to the foramen ovale and somewhat anterior to it. This in brachycephalic skulls DISEASES OF THE NERVES 315 is not infrequently so well marked as to hide the ganglion when approached by the low operation. When present, the summit of the elevation can be chiselled off without difficulty and a perfect exposure secured. When the entire ganglion is removed, trophic changes are apt to appear in the cornea, which, unless great care is used, lead often to ulceration and destruction of the eyeball. To avoid this complication, the eye should be protected against all irritation or trauma during the operation, and at its completion should be douched with boric' acid solution, closed, covered with a pad of sterile cotton, and protected by a separate bandage. This dressing should be removed daily after the first forty-eight hours and the eye carefully w r ashed and resealed. Tumors of the Nerves. — Tumors arising from nerve trunks are rare. They are generally of mesoblastic origin, and arise from the sheath of the nerve or the connective tissue between the fasciculi. The tumors most frequently encountered are the fibromata or fibroneuromata, myxomata, and sarcomata. A fibroma growing from the sheath of a nerve may produce no symptoms, as the nerve fibres may pass along one side of the tumor as a well-recognized cord and be in nowise affected by its growth. Occasionally, when the pressure on the neigh- boring parts produces compression of the nerve fibres, pain, numbness, and muscular disturbances are produced. This is especially true if the tumor develops in a bony canal. Fibromata growing from the interfascicular areolar tissue may cause a separation of the individual fibres of the nerve, which may be spread out over its surface. A well-recognized form of fibroma is the painful subcutaneous tubercle, which often appears along the branches of the cutaneous nerves, especially on the lower leg. The condition known as molluscum fibrosum is in many instances a group of fibromata growing from the cutaneous nerves. Fibroneuromata are tumors which contain nerve- elements as well as fibrous tissue, and are commonly observed in the bulbed extremity on the proximal end of a divided nerve trunk. Sarcomata and myxomata are rare, and are recognized by the usual characteristics of these growths. Treatment. — In regard to treatment, the same rules apply as in tumors of other tissues. Malignant tumors should be removed as early as possible; innocent tumors giving rise to painful symptoms should also be removed. Small fibromata occurring on important nerve trunks, not giving rise to symptoms and showing no tendency to increase in size, should not be molested. Tic Convulsif. — This affection is a spasmodic twitching of the facial muscles due to irritation of the seventh nerve. Its cause is obscure. It is often associated with severe neuralgia of the fifth nerve. If the disease is of a severe type and causes much discomfort, stretching the seventh nerve will sometimes afford relief. The nerve is best exposed by the method of Baum, which consists in a curved incision 316 INJURIES AND DISEASES OF THE NERVES beginning behind the ear opposite the external meatus and carried downward and forward around the lobule toward the angle of the jaw. The anterior border of the sternomastoid muscle is exposed and retracted backward, and the parotid gland drawn forward. This exposes the digastric muscle, along the upper border of which the nerve will be found. It is raised on a blunt hook and the tension maintained for two or three minutes, after which the wound is closed. In the severest cases, or in those in which nerve-stretching has not afforded relief, division of the main trunk of the nerve at its exit from the stylomastoid foramen and anastomosis with the spinal accessory or hypoglossal is indicated. Successful cases have been reported by dishing and Kennedy. Fig. 161.— Torticollis. (Whitman.) Torticollis. — Torticollis is a spasmodic contraction of the sterno- mastoid muscle alone or associated with other muscles of the neck, producing an abnormal attitude of the head with or without convulsive movements (Fig. 161). The disease occurs both as a congenital and an acquired affection. In the congenital variety the cause is often a hematoma of the sternomastoid muscle or a prenatal myositis, with subsequent contraction from atrophy of the muscular fibres and the formation of dense connective tissue. In the acquired variety the symptoms are often apparently due to some central irritation transmitted through the nerves supplying the affected muscles. It is frequently associated with neurasthenia, hysteria, and other neuroses; DISEASES OF THE NERVES 317 occasionally it is thought to follow trauma. In the congenital myel- ogenous variety, cervical scoliosis and asymmetry of the skull and face are frequently present. Cases seek relief from the surgeon only after medical means have been exhausted. Treatment. — The surgical treatment consists in tenotomy, myotomy, stretching or division of the spinal accessory nerve, or division of the posterior branches of the upper three cervical nerves. In the con- genital cases, where the muscle is found to be converted into a dense fibrous band, the operation of Mikulicz is to be recommended. This consists in exposure of the muscle by a longitudinal incision, division of its sternal and clavicular attachments, and complete removal of the degenerated portion, if necessary, as far as the mastoid process. After closure of the wound the position of the head should be over- corrected and held by a plaster-of- Paris cast. In the spasmodic variety nerve-stretching or neurectomy is indicated. The spinal accessory nerve can be exposed by a three-inch incision along the anterior margin of the sternomastoid muscle, beginning at the tip of the mastoid. The incision is carried down to the deep fascia, which is divided, and the space between the muscle and the carotid sheath exposed by retracting the tissues. The nerve will be found just below the posterior belly of the digastric muscle at a point where the latter crosses the transverse process of the atlas, and is identified by following it downward to the sternomastoid muscle, which it enters at a point opposite the angle of the jaw. The nerve is raised on a blunt hook and may be stretched or a portion resected. The nerve also may be reached by an incision along the middle of the posterior border of the muscle as it passes into the trapezius. Bailey has pointed out that complete paralysis of the sternomastoid and trapezius occasionally follows this operation, owing to the entire nerve supply being transmitted through the spinal accessory trunk. If the posterior muscles of the neck are largely involved, the trapezius, splenius, complexus, and trachelomastoid, the posterior branches of the first, second, and third cervical nerves should be divided. This is accomplished through an incision five or six inches in length extending from the occiput vertically downward about an inch from the spinous processes. The incision should divide the skin, fascia, and trapezius muscle; the edges of the muscle should then be well retracted and the splenius and complexus divided transversely. The posterior muscular branches of the three upper cervical nerves will be found beneath the complexus. These should be resected and the divided muscles united with catgut sutures. After closure of the wound the head should be placed in its normal position and retained by means of a plaster-of-Paris dressing. After healing of the wound, massage, regular exercises, hydrotherapy, and general tonic measures should be employed. Perforating Ulcer of the Foot. — Perforating ulcer of the foot is an indolent ulcer occurring generally under the ball of the great toe, and 318 INJURIES AND DISEASES OF THE NERVES showing no disposition to heal even under the most favorable con- ditions. The causes of this disease are, first, a condition of more or less complete anesthesia of the skin, associated with frequently repeated traumata; some interference with the trophic nerve control of the part, or both of these conditions may be combined. The disease is there- fore often associated with tabes, syringomyelia, and spina bifida. It is also occasionally encountered in diabetic or alcoholic subjects who suffer from neuritis. The surrounding skin is often anesthetic; the ulcer may extend to the bone and not infrequently results in necrosis. Treatment. — The treatment consists in rest and elevation of the part, hot poultices or wet dressings, with curettage of the ulcer and removal of the thickened skin, followed by packing with balsam or iodoform gauze. If these measures fail, stretching the sciatic or internal popliteal nerve may be tried. In the more obstinate cases amputation may be necessary. If in a diabetic subject, a proper diet should be prescribed and the urine rendered sugar-free when the ulcer in most cases will heal. OPERATIONS ON THE NERVES. Resection of the Cervical Sympathetic for Glaucoma or Exophthal- mic Goitre. — This operation is still on trial for these and other con- ditions. Sufficient data are not at hand to allow us to determine its value. The upper three cervical ganglia with the connecting cord may be exposed by an incision made along the entire length of the posterior border of the sternomastoid muscle. After division of the deep fascia and retraction inward of the muscle the carotid sheath is exposed. beneath which will be seen the gray cord of the sympathetic nerve. This should be followed upward and downward until the ganglionic enlargements are found and the cord divided above the first and below the third ganglion. Nerve Anastomosis. — The success which attended nerve suture in traumatic cases naturally led to the employment of nerve anastomosis with a view to restoring function in peripheral nerves which have been rendered functionless by trauma or disease (Fig. 162). Facial Paralysis. — As facial palsy is one of the most frequent and most disfiguring of the motor palsies, this was one of the first to receive the serious attention of surgeons. In 1895 Mr. Ballance, of London, performed the first facio-accessory anastomosis. Since that time numerous cases have been reported by Gushing, Korte, and others, with satisfactory restoration of function in the paralyzed nerve. Faeiohypoglossal anastomosis is advocated by Frazier, Taylor, and others, who report equally satisfactory results. In all of these cases during the period of gradual restoration of function, associated move- OPERATIONS OS THE NERVES 319 ments occur in the region formerly supplied by the active nerve trunk, when voluntary motion is attempted in the facial group of muscles. Operations should not be undertaken in Bell's palsy or non-traumatic paralysis of the facial nerve for at least six months after the onset of the symptoms, as cases are known to recover spontaneously up to that period. In traumatic cases the earlier the operation is performed the better, although recoveries are reported by these operations many years after the injury. The technic of the operation is comparatively simple. The region is exposed by a longitudinal incision along the anterior border Fig. 162. — Nerve anastomosis: A, intact nerve; B, paralyzed nerve; I, lateral anastomosis (peripheral implantation) ; II, lateral anastomosis (central implantation). of the sternomastoid muscle, the facial trunk recognized at its exit from the stylomastoid foramen, and followed well into the substance of the parotid gland until its bifurcation is reached. The spinal accessory is next exposed for a distance of two or three centimeters proximal to its entrance into the under surface of the sternomastoid muscle. The two nerves are then divided and an end-to-end suture practised, as shown in Fig. 163, the proximal end of the accessory being joined to the distal extremity of the facial. If the hypoglossal is employed, the technic is a little more difficult, as the nerve lies deeper. Some surgeons prefer to employ only a part of the functionat- 320 INJURIES AND DISEASES OF THE NERVES ing nerve for the anastomosis; others graft the peripheral end of the facial into the accessory or hypoglossal, making an end-to-side anasto- mosis (Fig. 162). In all cases the union should be protected by wrap- ping it in Cargile membrane, a bit of fascia, muscle, or fat. As success depends very largely upon primary union of the wound, the operation XV ^ Fig. 163. — Illustrating method of facio-accessory anastomosis. (Harvey Cushing.) should not be undertaken unless the surgeon can command trained assistants and the conditions necessary for a perfect aseptic technic. Brachial Nerve Paralysis. — Brachial nerve paralysis of traumatic origin occurs most frequently as a birth palsy. It is more rarely met with in later life as a result of an injury which forcibly separates the head and shoulder, or as the result of a gunshot or stab wound. In OPERATIONS ON THE NERVES 321 some cases of birth palsy the roots of the plexus are actually torn apart; in others the nerve trunks are so stretched as to cause a rupture K 3 iS o .3 "° -So a c3 .2H of the sheath and some of the fibres, with hemorrhage and the later formation of dense scar tissue, which effectually prevents nerve regeneration. 21 322 INJURIES AND DISEASES OF THE NERVES In the milder cases only the fifth root is injured; in the more severe injuries, the sixth, seventh, and eighth roots; or, in the severest, the entire plexus may be torn from the spinal column. In all of these cases a more or less complete paralysis of the upper extremity results. A study of Fig. 164 will enable one to estimate the extent of a given injury from the grouping of the paralyzed muscles. In the treatment of brachial birth palsy, at least six months should elapse before operation is performed, as a spontaneous recovery occurs in a certain proportion of the cases. Fig. 165. — 1, scalenus anticus muscle; 2, phrenic nerve; 3, internal jugular vein; 4, transversalis colli artery divided; 5, seventh cervical root; 6, omohyoid muscle; 7, fifth cervical root; 8, scalenus medius muscle; 9, sixth cervical root; 10, transversalis colli artery; 11, suprascapular nerve; 12, nerve to subclavius muscle; 13, clavicle; 14, nerve to scalenus anticus muscle. (Taylor, Clark, and Prout.) The operation consists in exposing the plexus by an oblique incision from the posterior border of the sternomastoid outward to the acromio- clavicular articulation. The incision is gradually deepened, the omohyoid muscle retracted or divided, and the plexus exposed, as seen in Fig. 165. The further steps of the operation are to be deter- mined by the lesions found. If one or more of the roots or trunks are completely severed, an attempt should be made to suture them after removal of their bulbed extremities. If this is impossible, an attempt should be made to anastomose live proximal trunks and the functionless distal branches. When the plexus is apparently intact, indurated areas should be sought for and excised, and suture, or anastomosis, carried out to restore function. After these procedures have been OPERATIONS ON THE NERVES 323 completed, the wound should be closed and dressed, and the head and shoulder approximated to relieve all tension on the anastomosed nerves. Successful operations have been reported by Kennedy, Taylor, and others. The nature of the injury is such that a complete restoration of function is seldom to be expected, and the number of carefully reported cases is, as yet, too small to enable one to make any definite statements regarding prognosis. p]nough has been demonstrated, however, to give rise to much encouragement in the surgical treatment of these otherwise hopeless and distressing conditions. Infantile Paralysis. — Infantile paralysis has recently been successfully treated by nerve anastomosis; also paralysis of muscles of the upper and lower extremities, due to destruction of nerve-trunks from com- pound fractures, lacerated wounds, and other forms of trauma. The principles to be followed in all of these cases are the same as in the conditions described above. When possible, the distal trunk of the functionless nerve should be anastomosed into the undivided trunk of a normal nerve by drawing the freshly divided end of the peripheral nerve into a longitudinal slit in the normal trunk, and securing it in place by sutures passed through its sheath. CHAPTER XV. INJURIES AND DISEASES OF HEAD AND BRAIN. ANATOMY OF THE SCALP. The skull is covered everywhere by soft parts, and depending on the situation, the constituent parts of this covering vary. Over the vertex of the skull stretches the scalp which is divided into the non- hairy and hairy scalp. This is composed of five layers: the skin, subcutaneous fat, aponeurosis or muscle, areolar tissue, and periosteum (Fig. 166). CEREBRAL VEIN [fc-CI MM subcutaneous TISSUE APONEUROSIS SUBAPONEUROTIC TISSUE PERICRANIUM SAGITTAL SUTURE PARIETAL BONE TWO LAYERS OF DURA LONGITUDINAL SINUS FALX CEREBRI Fig. 166. — Frontal section of scalp and skull through the sagittal suture and the superior longitudinal sinus. (Woolsey.) 1. The skin may contain numerous hairs which are gathered together somewhat roughly in groups of three to five, leaving a space in between which is free from hairs. The extent over which the hair is present varies with individuals and age. The scalp also contains sweat and sebaceous glands and small muscles, the erector pili. Beneath the skin there is a layer containing 2. Subcutaneous fat, which is arranged within the spaces of a fibrous meshwork, the trabecule of which run for the most part perpendicular to the surface. There are numerous bloodvessels, the main supply of the scalp, which run in these trabecule adherent to them by their outer surfaces. These trabecule bind the scalp to the aponeurosis beneath. ANATOMY OF THE SCALP 325 3. The aponeurosis is a strong, fibrous sheet of tissue which extends from the occipitalis muscle behind, forward, to the frontalis muscle in front. It is attached laterally to both the skin and the temporal fascia and gradually breaking up into various layers, the fat at the same time becoming more like that in the rest of the body. 4. The loose areolar tissue binds the aponeurosis to the underlying periosteum. It is so elastic that it permits the free movements on the skull which the scalp enjoys. 5. The periosteum is loosely adherent to the bone. It is, however, firmly attached along suture lines, and this is especially true in the very Fig. 167. — Diagram showing cutaneous areas of nerve distribution of face and scalp. (Gray.) young and the newborn. This attachment is due to the processes of the periosteum which project into the interstices of the sutures. The bloodvessels, both veins and arteries, run in the trabecule of fibrous tissue in the subcutaneous fatty tissue. The arteries anastomose freely one with another in all parts of the scalp. The veins communicate with those within the skull by means of the various emissary veins, the more constant of which are the parietal and the mastoid. There is also a communication via the angular and the ophthalmic in the orbit. The nerves of the scalp are derived for the most part from the fifth cranial pair through the following branches: frontal, supra-orbital, 326 INJURIES AND DISEASES OF HEAD AND BRAIN superficial temporal, auriculotemporal; also the occipitalis major, a branch of the cervical plexus (Fig. 107). The lymphatic radicals are collected into various large trunks and pass to the different groups of nodes as follows: 1. The frontal region, includes the bridge of nose, forehead, eyebrows and region anterior to the coronal suture, and the vessels from here pass to the parotid glands situated anterior to the external auditory meatus and angle of jaw. 2. The parietal or temporal region group is divided into two divisions — an anterior and a posterior. They drain the region from the coronal suture posterior for a variable distance, not, however, so far as the external occipital protuberance. The anterior group pass to the parotid glands, the posterior to the mastoid glands. 3. The occipital drain the remaining posterior region of the scalp and may be subdivided into two groups, an external and an internal. The external drain the more anterior portions of the occipital region and converge into a constant large single trunk which passes down to one of the sternomastoid glands in the neck. The internal group, on the other hand, pass to the occipital glands and then pass to the sternomastoid group. INJURIES OF THE SCALP. Injuries to the soft parts of the head may be either contusions, wounds, avulsions or burns. Contusions. — Contusions of the scalp are classified according to their situation, into: subcutaneous, subaponeurotic or subperiosteal. Subuctaneous contusions of the scalp are caused by blows of a blunt instrument striking the head, or by falls whereby the head strikes some hard, blunt object. The trauma is not sufficient to rupture the outer layer of the skin but causes a tear and rupture of the bloodvessels in the skin and in the subcutaneous fatty areolar tissue. The blood is extravasated into the surrounding areolar tissue and tends to gravitate to the most dependent portions, which accounts for the appearance of ecchymosis and edema of the eyelids following contusions of the vertex or frontal regions. When a large artery is ruptured the blood may accumulate very rapidly and give rise to a hematoma which at times has been known to pulsate. When the blood accumulates between the aponeurosis and the periosteum due to the rupture of the vessels in the loose tissue binding these two structures together we have a subaponeurotic hematoma, while with the accumulation beneath the periosteum stripping it away from the skull we have a subperiosteal hematoma. The two last varieties are apt to be circumscribed and surrounded by a firm dense encircling border of coagulated fibrin while the centre remains soft or even fluctuating. This condition may simulate very closely a depressed fracture of the skull, the ridge of coagulated fibrin being mistaken for the edge of the fracture. The PLATE XI Posterior auricular glands Occipital glands Maxillary glands — Parotid glands Buccinator glands Suprama ndibu la r glands Submaxillary glands Submental glands Inferior deep cervical glands Superficial Lymph Glands and Lymphatic Vessels of Head and Neck. (Gray.) INJURIES OF THE SCALP 327 mistake may be avoided by exerting slow, continuous pressure on the ridge, when it will be made to disappear and one may then pass the finger continuously from the bone beneath the softened central portion to the surrounding skull without encountering any inequalities or depressions. Process of Healing. — In the subcutaneous and subaponeurotic varieties the extravasated blood is eventually absorbed and leaves no trace, but often in the subperiosteal variety there is a formation of new bone about the periphery where the periosteum has been raised, and this remains as a permanent thickened area of bone. A contusion of the scalp, as a rule, runs a course without accident or complications. The swelling appears promptly after receipt of the injury, especially in the subcutaneous variety. The pain, which at first is sharp and severe, soon subsides. The ecchymosis does not appear, as a rule, until after twenty-four hours, and may continue to increase for another twenty-four hours, rarely longer. The area is painful to pressure, firm in the subcutaneous variety but may have a softened central portion surrounded by a firm, dense rim in the sub- aponeurotic and subperiosteal varieties. These latter usually form more slowly, and while the subcutaneous variety rapidly disappears, in twenty-four to forty-eight hours, the latter varieties may persist for long periods and may require special treatment, as incision. and drainage, to bring about a cure. A special form of subperiosteal hematoma, which presents some peculiarities and which is not an infrequent result of instrumental delivery during a difficult labor, is the cephalhematoma. The peri- osteum in a newborn infant is comparatively thick, dense and firm, and along the sutures between the bones it is intimately adherent to the dura mater. In these cases the blood, extravasated beneath the periosteum, raises it away from the bone, usually to its full extent, but does not extend beyond its borders. It usually takes twenty-four hours to develop, occurs most frequently under the parietal bone and is absorbed very slowly, at times remaining several months before it entirely disappears and then oftentimes leaves a ridge of thickened bone about its periphery. Scrupulous care should be taken to prevent infection by pathogenic micro-organisms as this is extremely serious and may end fatally. Absorption usually occurs in eight to ten weeks. Any one of these varieties may become infected with pathogenic micro-organisms, which is especially liable to occur when, in addition to. the contusion, there is also an abrasion of the scalp. This must be treated as a cellulitis or abscess of scalp. Treatment. — The application of ice-cold compresses usually relieves the pain and tends to diminish the swelling in the subcutaneous contusions or hematomata. A moderated amount of pressure by a dry gauze compress and bandage will control somewhat the extrava- sation in the subperiosteal and subaponeurotic varieties. In certain cases where absorption is particularly slow, one can draw off the fluid 328 INJURIES AND DISEASES OF HEAD AND BRAIN with a trochar or make a small incision at the most dependent portion. The fluid is usually dark maroon to brown in color, contains fat droplets and crystals of hematoiden. The greatest care should be exercised to maintain asepsis during these procedures, and pressure with a compress and bandage should be applied and maintained for three or four days. Wounds. — These may be classified, as are wounds elsewhere in the body, into incised, punctured, lacerated, gunshot, and wounds with loss of substance. Incised wounds are made by sharp, cutting instruments and may involve only the skin, or may extend deeper, even down to the bone. They may be caused by blunt instruments also, owing to the peculiar manner of attachment of the tissues to the bone. The blunt instru- ment strikes the scalp obliquely and moves the scalp on the underlying bone until the scalp is torn in a sharp line at the periphery of the area moved and usually on the side from which the blow is struck. The edges of an incised wound are clean cut and bleed freely as the vessel's lumen is kept open on account of their walls being held apart by the fibrous trabecular in which they run. The wounds which run transversely across the head, dividing the aponeurosis, gape more than those running in the opposite direction, as the contraction of the muscular bellies pulls them asunder. Punctured wounds are caused by small, sharp instruments. They usually have a short course and often the bone is injured, also the point of the instrument may be broken off in the bone. At times the punctured wound has a long tract and the instrument may have made a wound of exit. Unless a branch of some large artery has been injured the bleeding is slight. Lacerated wounds of the scalp are by far the most frequent and are characterized by having a bizarre, oftentimes stellate, form; the edges are ragged and irregular, and, because they are usually caused by some blunt object, the areas in the immediate vicinity are contused and show abrasions. Inasmuch as the scalp is torn, the bleeding is less than in the incised variety, except where a large arterial branch is injured. Treatment. — Incised, punctured, and lacerated wounds of the scalp should be treated with intelligent care along the principles of antiseptic surgery, and because the wound is small and often insignificant, it should not be neglected, but should receive as much attention as larger wounds elsewhere. The area about the wound should be shaved for about one inch, a piece of sterile gauze having been previously packed into the wound to prevent any fresh contamination. The scalp should then be scrubbed with green soap and water with a scrubbing brush. If there is any foreign material in the wound it should be removed. This may be composed of hair, street dirt, particles of clothing, and should all be removed. The wound and the surrounding area of scalp should then be disinfected with half-strength tine- INJURIES OF THE SCALP 329 ture of iodine. This is a most painful process. All bleeding ves- sels which show a change of rate synchronous with the heart beat should be ligated. This may be at times a difficult task and may be only, or best, accomplished by sutures which also tend to close the wound. The edges of the wound should be approximated as accu- rately as possible, care being taken not to turn in nor invert the skin. The suture material best adapted to this purpose is horsehair, or fine silkworm gut. Silk may be used, but it tends more to subsequent infection. As a rule, scalp wounds should not be drained, unless evi- dences of cellulitis and infection by micro-organisms are present. The fact that the wound is not clean, but contains infective material, even microscopic particles, is no reason for drainage, provided the wound is seen a comparatively short time after the injury. The scalp is so vascular that it can take care of a great deal of infection, and the tissues also appear to possess a certain heightened immunity. When one of the deeper structures is divided, as the aponeurosis, it should be coapted with catgut sutures as accurately as possible. It may be deemed advisable to drain certain wounds in which a flap of tissue has been raised up or there has been considerable undermining of the deep attachments, but even in these cases healing will proceed much more smoothly if the surgeon expends his energies, rendering the wound as clean as possible when it is first seen and cared for, than if he trusts to drainage to carry off the infectious material. Scalp wounds of moderate size may be dressed with plain sterile gauze, which is held in place by collodion or adhesive plaster. Large ones, of course, will require a proper bandage to retain the dressing in place. Scalp wounds heal rapidly, and in seven days even the largest are closed and stitches may be removed. At times a slight infection may be averted by an early removal of the stitches, for instance, after forty-eight hours. Gunshot wounds of the scalp uncomplicated by visceral injury are rare and do not offer any peculiarities over the same class of wounds elsewhere. They are usually, however, complicated by wounds of the skull or its contents and will be taken up more fully in gunshot wounds of the brain. Wounds of the scalp with loss of substance may assume serious impor- tance in direct proportion to the size of the tissue lost or the area of the skull left exposed. On account of the unyielding, non-compressible char- acter of the skull it may become impossible to cover completely the exposed bone. The same scrupulous care in cleansing the wound should be taken as in the simple scalp wounds. They should be dressed with a bland ointment (10 per cent, boric acid) and the bone left to granulate. Often large areas of .bone denuded of periosteum will maintain their nutrition and granulate, when they may be grafted or covered by means of a plastic operation. In the cases in which necrosis follows only the outer table of the skull exfoliates, as a rule, at least in adults. In children and infants it is more serious as the dura mater may become exposed owing to the death of the skull and fatal meningitis 330 INJURIES AND DISEASES OF HEAD AND BRAIN ensue. The process of repair is a tedious one, often taking several months before the exfoliation of bone is complete and the exposed area covered by granulations. Avulsion. — Avulsion of the scalp is an unusual injury, and consists of a tearing off of the scalp from the skull. It occurs most frequently in women and girls. It is usually the result of having the long hair caught in machinery or belting and wound up rapidly. As soon as the victim feels the pull she quite instinctively throws up her hands, clutches each side of her head, and exerts a counter-pull. The line of avulsion varies somewhat, but in general extends from the region of the eyebrows back along the zygoma, above the ear and down the back, following about the line of growth of the hair. It may only remove the skin and subcutaneous tissue, but usually some portion of the aponeurosis and even the periosteum is also torn off. The patient may immediately lose consciousness, or she may retain consciousness but exhibit evidences of profound shock, as pallor, apathy, superficial respiration, weak, thready pulse, and cold sweat. The hemorrhage is at first profuse but not excessive, the vessels from the bone being the last to thrombose. Most patients recover from the shock, the bleeding ceases and we then have a large extensive raw surface with no skin available for covering it, by means of a plastic operation. Treatment and Course. — The loss of blood may be alarming from the larger arterial trunks, notably the temporal and occipital, but in many cases these do not bleed, as the inner coat curls up, and the vessels thrombose due to the tearing violence which ruptures them. When these vessels bleed they must be ligated. The capillary hemor- rhage can best be controlled with gauze compresses. The wound is not usually very septic, but it should be thoroughly cleansed with sterile water and saline solution. All attempts to make the scalp adhere have failed when the avulsion has been complete. The wound should be dressed with boric acid ointment or gauze soaked in alboline. Wet dressings give a sensation of cold and are disagreeable. The periosteum soon forms granulations, and even the areas of bone which are denuded of periosteum may granulate and heal without necrosis. Later the wound must be covered with Thiersch grafts. Infection of the wound with thrombosis of the emissary veins and consequent meningitis has occurred and been the cause of a fatal termination. Burns. — Burns of the scalp may be superficial or deep, involve large extensive areas, or be quite circumscribed. Blisters do not form, as the serum leaks out along the hairs and does not remain confined beneath the epidermis. Healing is slow and painful and the edema which occurs is much more extensive than in burns elsewhere. In deep burns the hair follicles are destroyed and baldness often results. The danger of infection by pyogenic organisms invariably is present and may prove a serious complication. Superficial first-degree burns or scalds may be left untreated. As they are very painful the adminis- DISEASES OF THE SCALP 331 tratioD of an anodyne may be necessary. They usually heal in a week to ten days. The deep burns are best treated by the open method, leaving the area exposed to the drying action of the air. The hair should be cut close over the burned area, if it has not already been destroyed, and for a wide area about the burn. Large granulating areas must be covered by skin-grafts. Necrosis of the skull often follows extensive destruction of the scalp from burns. DISEASES OF THE SCALP. Cellulitis. — The scalp is subject to the same pathological processes as are other portions of the body, but these are modified by the prox- imity of the skull and its contents both in respect to their importance and their prognosis. All accidental wounds of the scalp are infected wounds. In the majority of cases if the wound is carefully cared for and in the correct manner, the infection is taken care of and the wound heals primarily. In a certain number of cases, however, the infection increases and there results one of the many forms of inflammation of the scalp. The most frequent is cellulitis about the immediate vicinity of the wound. This is evidenced by redness, pain, and swelling along the edges of the wound. The redness, as a rule, is very moderate, which is true of all infections of the scalp where redness is either absent or very slight. The swelling, on the other hand, is well marked, is a soft edema, and extends over a wide area. The pain is not excessive and is rather less in degree than elsewhere in the body. The presence of pus in the wound is often not readily made out, as fluctuation is not easily demonstrated. The lymphatic glands of the group into which the radicals from the infected area drain, become tender, swollen and firm. Treatment. — When there is no suppuration the removal of the stitches from the wound and an antiseptic wet dressing of bichloride of mercury (1 to 2000), or a solution of aluminum acetate, often results in resolution and healing. Whenever pus has formed it is best to remove all the sutures and separate the edges of the wound and pack with gauze moistened with sterile alboline. This will keep the edges of the wound apart and allow free drainage. The wound should be dressed and the packing removed within twelve hours. The alboline prevents adhesions forming between the edges of the wound and the gauze, so that no, or only a very slight, amount of hemorrhage will result from removal of the dressing. Furunculosis. — Furunculosis of the scalp requires the greatest care in cleansing the scalp. The hair must be shaved about the furuncle and care taken that the discharges from the opening do not infect other areas. Treatment should aim at incision of the furuncle, drainage of wound and disinfection of discharge and secretion by dressings of bichloride of mercury or aluminum acetate (1 to 1000), and frequent 332 INJURIES AND DISEASES OF HEAD AND BRAIN enough changing of these, so that they shall not become soaked with the wound discharges. Abscess. — An abscess of the scalp without some disease of the bone of the skull is a rare affection. It may arise from infection commencing from an abrasion or from a hematoma. The symptoms do not in any way differ from abscesses elsewhere, but the proximity of the skull and its contents gives rise to possible dangers from the extension of the process to them. Its treatment is incision and drainage. The incision should be so planned as to avoid as much as possible the main arterial trunks, and this may be accomplished best if they are made radically from the vertex or bregma. Erysipelas. — Erysipelas of the scalp is not a rare form of the disease and it differs from erysipelas elsewhere in many respects. It may originate from a wound of the scalp, however small itself, but this is unusual, as it is most frequently an extension from a focus elsewhere and generally follows erysipelas of the face, when the process extends from before backward. Symptoms. — -The anatomical peculiarities of the scalp modify in a marked degree the course of erysipelas. One will seek in vain for the redness of St. Anthony's fire, for the sharply defined, slowly advancing border, raised above the surrounding normal areas, and for the presence of bullae, but will find a soft, baggy swelling, diffuse and not well demarcated, and excessively tender to pressure where it is advancing. This painful characteristic is often the best criterion as to the advanced limits of the disease. There is apt to be delirium of a more or less violent nature, and there may be stupor or even coma. The temperature is high and the pulse is rapid. The patients show signs of a severe illness and the effects of an acute, profound infection, with dry tongue, loss of appetite, nausea and vomiting. Though delirium, stupor and coma frequently accompany an attack of erysipelas of the scalp, and there is often muscular twitching, meningitis is a rare and unusual sequence, and when it does occur it is due either to suppuration and the formation of a diffuse phlegmon, or thrombosis of an emissary vein and so an extension of the infection to the meninges. Course. — The disease usually lasts seven to nine days, but may be prolonged over a much more extended period. As it progresses it passes from before backward and may invade the trunk. When this occurs it passes down the back of the neck and extends to the chest, arms, and back. Even should the first focus be in the frontal region it rarely extends to the face. The hair usually falls out after a severe attack but it will return after six months to a year. Treatment. — Treatment is for the most part expectant with careful nursing. Local applications of boric acid in saturated solution, ice-cold, frequently changed, will aid in controlling much of the discomfort. Shaving the scalp to permit the application of ointments is not good practice as there is no local application which is universally successful in controlling the spread of the disease. NEW GROWTHS OF THE SCALP 333 NEW GROWTHS OF THE SCALP. Lipoma. — This is a rare tumor constituting about 2 per cent, of all lipomata. It occurs most frequently in adults of advanced years, but cases have been reported in which the new growth began in early life. It is situated most frequently in the frontal region, next occipital, then temporal and parietal. Pathology. — It is usually situated in the loose areolar connective tissue beneath the aponeurosis of the occipitofrontalis muscle. About its periphery the periosteum is raised into a firm, dense, thickened ridge. As a rule, there is no depression in the bone, but in rare instances such has been observed. The lipoma is not lobulated, although there are numerous fibrous trabecule running through it which bind it firmly to the periosteum. Symptoms. — Lipomata, as a rule, are broad, flat, sessile growth, like half of a flattened sphere, rarely pedunculated. They are not lobulated. The skin over them is unchanged and quite normal. The tumor is usually soft, almost fluctuating, and rarely elastic. The skin can be moved over it and raised into folds. The tumor is smooth and does not move to any great extent on the deeper parts. It is not painful. The growth is slow. Treatment. — Removal of growth by operation. Sebaceous Cysts. — These are the most common of the swellings of the scalp. They are most frequently seen in women. They are rare in early adult life, and are never observed before fifteenth year, being most often observed in old or elderly persons. Pathology. — They develop from the sebaceous glands along the roots of the hairs. They consist of a quantity of sebaceous material enclosed in an epithelial lined cavity, the cells of which are derived from the cells of the sebaceous gland from which the cyst developed. There are several layers of epithelial cells in the wall. The duct generally is closed in the cysts in the scalp, though it is often open in those found elsewhere in the body. The cysts found in the scalp are always disconnected from the skin lying in the subcutaneous tissue. They are never beneath the aponeurosis of the muscles. Symptoms. — They cause no discomfort and only their appearance annoys. When small they are round but as they increase in size they often become flattened as the scalp presses them against the bone. They have been described as pedunculated, but this is exceedingly rare. When several are situated near one another they may be separated by a groove only. As they develop the skin over them becomes thinned and the hair atrophies and drops out leaving a bald area. This often appears paler than the surrounding scalp. At times a comedo may be made Out on the summit. They vary in size from 0.5 cm. to 10 to 15 cm. in diameter. On palpation the small cysts are hard and shotty, while the large ones are doughy, soft, elastic and when infected, fluctuating. Their 334 INJURIES AND DISEASES OF HEAD AND BRAIN consistency is uniform. The skin does not move readily over the small ones, but may over the large ones. They move on the deeper parts. They rarely disappear spontaneously, but may rupture, discharge their contents, and form fistula? which close and the secretion reaccumu- lates and again discharges. They may become infected, when the contents become fluid and discharge, by involvement of the skin with resultant thinning and necrosis. The sac often sloughs out when a permanent cure results. At times they undergo calcareous degenera- tion when hard plates may be felt in the walls. In some instances a malignant change has occurred in them. Treatment. — The removal of the wall of the cyst is necessary to insure a permanent cure, for if a small portion remains it will develop a new cyst. They may be readily removed under local anesthesia (0.5 per cent, novocaine solution). Dermoid Cysts. — These are rare on the scalp. They appear usually in the first two to three years of life, but may be noted earlier ; at the latest about puberty. They probably have been present at birth but have not been noticed until a later date. Pathology. — They are the result of an inclusion of the ectoderm about the ninth to fifteenth day. The wall is composed of all the elements of the skin, with its appendages, hair, sebaceous and sweat glands. The contents vary somewhat; oftentimes sebaceous material, at times brownish, due to hemorrhages into the sac; it may be oily or even serous. In the latter case it may simulate a cephalocele, especially if the skull beneath it is defective. They are situated beneath the aponeurosis and may have an attachment with the dura. Symptoms. — Dermoid cysts give no discomfort. The skin is unchanged over them. They are usually single and occur most often in certain situations — at the outer end of the supra-orbital ridge or adjoining temporal region, inner angle of eye, glabella and root of nose, over the site of the large and small fontanelle and in the parietal occipital suture and mastoid region. Certain of them occur in the orbit when they communicate by a prolongation with a process in the temporal fossa. They have an elastic or doughy consistency. The skin moves readily over them and they do not move on the deeper parts. They are of slow growth. Treatment. — Complete removal under local anesthesia (0.5 per cent, novocaine solution) is the proper procedure in the superficial varieties; in those connected with the dura, general anesthesia may be necessary. ANATOMY OF THE SKULL. The skull is divided into face and cranium or cranial cavity, which is again divided into vertex and base. The vertex is composed of thin, flat bones, having an outer and an inner layer of compact bone, the inner and outer tables of the skull, between which is a layer of cancellous bone, the diploe. The base is more irregular and contains many ANATOMY OF THE SKULL 335 cavities, and is perforated by foramina so that it is of varying thickness and strength. Lines of fracture through the base are influenced greatly in their course and direction by these masses of varying thick- ness and by the foramina. The cranial cavity is lined by a firm, dense membrane, the dura mater, which is firmly adherent to the bone and serves as its inner periosteum. It also separates different portions of the brain from one another by sending processes in between them, and it supports venous channels between its layers, by which the blood is conveyed from the veins of the brain and skull to the veins of the neck. The arterial supply to the skull also runs in the dura mater. It is lined internally by a layer of pavement-endothelium. The sinuses of the dura mater are lined by endothelium and receive blood from the dura mater, brain and skull. Their walls, composed of dura mater, are firm, and do not collapse when empty of blood. They contain no valves. They all run toward the jugular foramen and, with few exceptions, empty their contained blood into the jugular veins. They communicate, however, with the general circulation at other points, namely, through the ophthalmic vein, vertebral plexus and various emissary veins, as the mastoid and parietal. On either side of the superior longitudinal sinus we have more or less extensive spaces filled with blood, the parasinoidal sinuses or lateral lacuna?. These are extensions laterally of the lumen of the sinus. The Pacchionian bodies project into them as do various processes of the pia mater. The pia arachnoid covers the outer surface of the brain and cord and fills in the space between the brain and dura mater. Formerly these were considered as two separate structures, but it is much better and more correct to consider them as one structure composed of two more or less well differentiated portions, which differ somewhat in their histological appearance and character. The pia mater lies closely applied to the outer surface of the brain and sends processes in between the convolutions. The bloodvessels of the brain are supported by the pia, which is a firm, fibrous coating, the fibres of which are continu- ous with those of the arachnoid. This, on the other hand, is a wide meshed network of fibres which divide the space between dura mater and pia mater into many compartments of varying size which are filled during life with a colorless fluid, the cerebrospinal fluid. The cerebrospinal fluid is secreted by the cells of the choroid plexus, flows through a slit in the descending horn and through the foramen of Magendie into the cisterna magna. In health it has the following characteristics: there is about 60 to 150 c.c, and only from 20 to 30 c.c. of this is in the ventricles of the brain, the remainder being in the subarachnoid space. It is a clear and limpid fluid, colorless, faintly alkaline, sp. gr. 1.000 to 1.003; contains a faint trace of albumin, 0.2 to 0.5 per cent.; gives no distinct nucleo-albumin reaction: at times it contains a substance, which reduces Fehling's solution, either glucose or pyrocatechin; it also contains chalin cholesterin. The potassium 336 INJURIES AND DISEASES OF HEAD AND BRAIN content is greater than that of sodium. Normally it is under a pressure of 60 to 100 mm. of water; in disease this may be greatly increased, even as high as 200 to 800 mm. of water. It normally contains a few cells, while in pathological conditions this number may be greatly increased. The cerebrospinal fluid is absorbed mainly by the veins, especially the processes of the pia arachnoid which pro- jects into the parasinoidal sinuses. It is absorbed, but very slightly, by the lymphatic vessels of the nose, the sheaths of the nerves, notably the optic and the perilymphatic space of the labyrinth of the ear. The circulation of the brain is derived from arteries which run in the pia mater. They form a rich network over the cortex of the brain, and are true end-arteries in the cerebral substance. The veins have four times the capacity of the arteries. They have thin walls, are without valves and many of them lack a muscular coat. The blood is brought to the brain under high pressure and the return flow is free and unimpeded in the veins where the pressure is low. INJURIES OF THE SKULL. Fractures of Skull. — Their main importance is due to possibilities of what in other fractures would be termed complications or accom- panying lesions, namely, those to the neighboring soft parts. Fractures of the skull differ from fractures elsewhere in that the function for which the skull is intended, namely, the containing and protecting of the brain, may be seriously interfered with by the fracture; therefore vis- ceral injury, or injury to vessels and nerves with their consequences are much more dangerous than elsewhere. Classification. — Fractures of the skull are divided into those involving the vault, those of the vault radiating to base, and those of the base: also those without brain injury and those associated with brain injury. Frequency. — According to different statistics these range from 1.45 per cent, to 3.8 per cent, of all fractures. Causation. — Outer Table Alone. These are caused by sharp instru- ments, or a glancing blow, and may divide the outer table only. They are rare. Inner Table Alone. — A blunt instrument may bend the skull, and the inner table being on the concave side of the arch, undergoes a separating force, while the outer table undergoes a compressing force, and in consequence small fragments may be driven off from the inner table, leaving the outer table uninjured. This also is rare (Fig. 168). Circumscribed without Displacement. — A small, blunt instrument, as a hammer or stone, or other missile, strikes the skull with sufficient violence to cause a fracture about the periphery of the area of contact of the vulnerating body, but the force is arrested and spends itself in causing the fracture, and in consequence, the fragment of bone remains in place. This also may result from falls on the head, especially on the frontal' eminences. INJURIES OF THE SKULL 337 Circumscribed with Displacement. — This occurs when the force driving the vulnerating body continues to act after the skull is fractured and the fractured portion is driven inward and becomes caught beneath the edge of surrounding bone, and remains in this new abnor- mal position, held fast by the pressure of the cranial contents. These last two forms are often comminuted and there coexist radiating lines of fracture extending into the surrounding skull (Fig. 169). Bursting Fractures. — These are caused by a violence acting over a wide area of the skull and give rise to a shortening of the diameter of the skull in the direction of the force's action. There results from this a widening of the skull in a direction at right angles to the direction of the force, and this gives rise to fractures parallel to the direction of force. They may be of the base or the vault, or involve both. Bending Fractures. — At times the force acting over a wide area of the skull causes a fracture at the edge of the area on which the force Fig. 168. — Mechanism of fracture Fig. 169. — Circumscribed depressed fracture, of the internal table by bending of (Konig.) the bone. acts and the line of fracture is then at right angles to the direction of the line of force. These may be through the base, but usually involve both the vault and the base, or the vault, alone. The line of fracture may be in any direction, but there are certain lines which the fracture commonly follows. These lines are probably largely determined by the presence of foramina and the thickened portions occupying the base of the skull. They are as follows: . 1. Line commences anteriorly at ethmoid plate near the crista galli, or laterally from it, then passes through the orbital plate of the frontal bone to the optic foramen in the lesser wing of the sphenoid; thence to foramina rotundum and ovale in the greater wing of the sphenoid; and then either (a) laterally toward the squamous portions of tem- poral bones, or (b) posteriorly through the middle lacerated foramen and jugular foramen on anterior and posterior border of the apex of the pyramidal process of the temporal bone to the foramen magnum, and posterior through the thinner portion of the occipital bone. 22 338 INJURIES AND DISEASES OF HEAD AND BRAIN 2. Line passes transversely or obliquely through the sella turcica in the thin roof of the sphenoid sinus from the foramen rotundum of one side to the middle lacerated foramen of the opposite side. 3. Line passes through the occipital bone and the pyramidal process of the temporal bone between the hypoglossal canal, jugular foramen, acoustic foramen and foramen spinosum. 4. Line of fracture extends about foramen magnum "ring fracture," following a fall on the feet or buttocks or on top of the head, where the spinal column acting through condyles, punches out a ring of bone about the foramen magnum. 5. The posterior clinoid processes by a pull on the tentorium when the anteroposterior diameter is lengthened, may be torn loose. (See Figs. 170 to 174.) Fig. 170. -Bursting fracture of the base. (Von Bergmann.) Fig. 171. — Circular fracture of the base. (Von Bergmann.) Symptoms. — The symptoms referable to the fractured cranial bones are often not prominent and may be absent altogether. The diagnosis is often established by a history of trauma, and the presence of injuries to the neighboring soft parts. The pain is moderate, and often it is only a headache of which these patients complain. In circumscribed fractures of the vault with displacement of the fragments the deformity may be readily palpated, the various other forms give no such data. The basal fractures are not infrequently accompanied by hemorrhage from nose, mouth or ear. Hemorrhage from the nose is not, however, a symptom on which much diagnostic reliance can be placed because it is such a frequent occurrence in so many injuries which are trivial in character. Hemorrhage from the mouth also is not a very reliable sign, on account of the many chances there are by which the bleeding may arise from biting the tongue or other minor injury; but it is a INJURIES OF THE SKULL 339 frequent symptom in fractures through the posterior fossa involving the body of the sphenoid or occipital bones, resulting in a tearing of the Fig. 172. — Longitudinal fracture of the base. (Von Bergmann.) Fig. 173. — Fracture of base, from fall from scaffolding. Hemorrhage from right ear and nose. Death from meningitis. (Von Bergmann.) posterior vault of the pharynx. Hemorrhage from the ear, on the other hand, is of very much greater diagnostic value, because it always Fig. 174. — Bursting fracture. Patient slipped, striking head on stone. Direction of force indicated by arrow. (Von Bergmann.) implies a severe traumatism and it is easier to rule out possible sources of origin other than that from fracture. These possible sources which 340 INJURIES AND DISEASES OF HEAD AND BRAIN might lead to an error are injuries to external auditory cana], rupture of drum membrane, fracture of tympanic plate and rupture of mem- brana tympani. At times this membrana tympani remains intact and there occurs an accumulation of blood behind it which on otoscopic examination gives rise to a dark bluish appearance to the drum. In addition to the hemorrhage from the ear, or independent of it, there may be an escape of a thin, watery discharge. It is highly important to discover the exact nature of this discharge. It may be the cere- brospinal fluid, which is pathognomonic of fractured skull. The flow is abundant and prolonged, at first mixed with blood, later quite clear, comparatively rich in chlorides and containing a small amount of albumin. It may be lymph from the vessels communicating with the inner ear. The amount may be large, the fluid will have a high albumin content and contain no chlorides. The clear discharge may be due to inflammation of the middle ear, abundant at first, and containing a large amount of albumin, while later becoming scanty and purulent. The extravasation of blood with formation of a clot may give rise to a discharge of serum. This will appear late, some days after injury, be pinkish in color and contain a large percentage of albumin. The .r-ray examination often will reveal the presence of a figure or fracture of the skull. Treatment. — Treatment of fracture of the skull is for the most part expectant. Rest in bed with an ice-cap for the severe headache, and morphine or codeine as sedatives. The lesions to the soft parts, brain, nerves, and bloodvessels must be treated quite independently of the fractured skull. It is advisable to have a very careful watch kept over a patient in whom a fracture of the skull is suspected; have his pulse counted at frequent intervals; also his blood-pressure should be taken often. A patient in whom a fracture of the skull has occurred should be kept in bed for a week after the disappearance of all symptoms directly due to the fractures, and then, if no complications are present, be allowed to move about gradually. In cases of circumscribed fracture with displacement, a formal operation should be undertaken, and the displaced fragments either removed or replaced in their normal position. In all these injuries one should examine carefully the inner side of the displaced fragment for detached fragments or splinters of bone, which if left may give rise to severe late complications, pressure, epilepsy, etc. In basal fractures with symptoms of increasing pressure, which develop gradually, a subtemporal decompressive operation should be performed. In these cases where the pressure symptoms supervene immediately after the receipt of the injury and develop with exceed- ing rapidity probably no operative measure will prove efficient to save life. The mortality is high and the results of interference are not brilliant, but operation holds out the only chance and it is the opinion now that except in moribund cases, decompression gives the best prognosis. DISEASES OF THE SKULL 341 DISEASES OF THE SKULL. Osteomyelitis. Osteomyelitis of the crania] bones is a rare affec- tion. It may be acute <>r chronic. Of the acute, dependent on its mode of origin, we distinguish several varieties, as spontaneous, traumatic and secondary. An acute, spontaneous osteomyelitis may develop without any local cause being discernible, similar to the osteomyelitis of the long hone- in children. It is a rare affection, almost exclusively in young people. Etiology.- Any and all wounds of the body which can serve as a point of entrance to the organism, acute, infectious diseases in the period of their convalescence, and any debilitating condition which lowers the child's resistance, may be etiological factors. Traumatism which does not break the skin will often determine the site of the lesion. At one time Staphylococcus aureus was thought to be the specific organism of all osteomyelitis, but now this is known to be incorrect, and we may have Staphylococcus albus or citreus, pneumococcus, streptococcus, typhoid bacillus and certain anaerobic bacteria. Pathology. — The infection is brought to the site of the disease by the blood current and lodges in the bone. The lesions do not in any way differ from those of osteomyelitis elsewhere as in the long bones; intense congestion of all the constituent parts of the bone, hyperemia of the periosteum with the formation of hemorrhagic foci, subperiosteal edema, hyperemia and congestion of the diploe. These lead rapidly to suppuration, small foci of pus colleet beneath the periosteum and in the diploe. The bone may rapidly lose its vitality, areas of necrosis are found which at first are white, then change to black and have a foul odor. The sequestra, however, are formed only after a considerable time and not in the early stages. The sites, in order of frequence, are the frontal, parietal, and temporal bones, and vary rarely the base of the skull. Symptoms. — Onset is sudden with high temperature, 104° or 105°, often accompanied by chills. There is headache of an intense lancinat- ing character, often throbbing which is worse at night, and not relieved by treatment — at time-, it i- frontal, occipital or general. There is great thirst. The patient looks profoundly ill and prostrated. Often there is epistaxis which recurs and is repeated many times, and there may be convulsions. The tongue is dry and coated. There may be marked tenderness over the site of infection on the head. The pulse is rapid. weak and soft. There is often alternating diarrhea and constipation. The course of the disease i- very rapid; the patient is acutely ill, with stupor, delirium and a typhoid state ending in coma and death. Many of the symptoms are masked by seme of the complications due to the involvement of neighboring structures, when the picture will be that due to involvement of those structures, meningitis, throm- bophlebitis, sinusitis, abscess of neck; or there may be distant lesions, 342 INJURIES AND DISEASES OF HEAD AND BRAIN as endocarditis, pneumonia, empyema, and any of these may mask the picture of osteomyelitis and lead to an erroneous diagnosis. The local manifestations may not become evident for many days and the general complications may give the picture to the disease. Treatment. — This must be radical and prompt, and consists in removing the diseased bone, exposing the dura and providing ample and efficient drainage. Traumatic Osteomyelitis. — The traumatic type is an acute osteo- myelitis which follows injury associated with an infected wound. Adults are most often affected. The trauma may or may not cause a break in the skin, but wounds which expose the skull are the ones which most often are followed by infection of the bones. The infection may be by any of the pyogenic organisms. Pathology. — There is usually a superficial involvement of bone, rarely the entire thickness of the skull, but simply an exfoliation of the outer table. But when large areas of bone have been denuded the sequestra are correspondingly large and irregular in shape. Symptoms. — The onset is gradual and often not associated with any general disturbance, but at times there is a distinct febrile movement as the sign of a bone involvement. Pain is not such a prominent symptom as in the previous variety, but still it is often present and apt to be worse at night ; it is not necessarily localized to the area of infected bone but may be generalized. Bare bone is often seen but it is impossible to state by inspection whether there is an osteomyelitis or not. The bone may be felt, but bare bone is not necessarily dead bone, or even infected bone. The course of the affection may indicate whether in any given infected wound there had occurred an osteomyelitis. A persistent sinus discharging pus leading down to bare bone, the presence of a sequestrum, persistent fever with headaches, pain and tenderness in region of wound, would lead to the diagnosis of osteomyelitis. Treatment. — This should be guided largely by the course of the dis- ease and the amount of fever. If there is high fever and an extensive infection, a radical removal of bone would be indicated, but as a rule conservative treatment is the best procedure. Chronic Osteomyelitis. — Chronic osteomyelitis is a much more common affection. It may be caused by middle-ear disease, acute osteomyelitis resulting in the formation of a sequestrum, or necrosis. Pathology. — A chronic suppurative process resulting in death of bone with or without sequestra, caries and slow bone absorption. Pus may form between the bone and dura and give rise to an extradural abscess with symptoms of cerebral compression. Symptoms. — Chronic osteomyelitis gives rise to the long-persisting sinuses which discharge pus in variable quantities. When the dis- charge is slight in amount the sinus may crust over and appear to heal up, only to break open again with pain and a discharge of increased amount of secretion. This may persist for years, notably the chronic DISEASES OF THE SKULL 343 disease in the middle ear. From time to time and often without discernible cause the process will light up and give symptoms of an acute osteomyelitis with chills, rigor, fever, headache, malaise, nausea, and vomiting. This corresponds usually to a fresh extension of the process, or to accumulation of pus under tension. Chronic disease of the bones of the skull is one of the frequent causes of brain abscess. Treatment. — Treatment must be carefully carried out, and great care taken not to convert the chronic process into a virulent active, acute one. Operative interference must be designed to remove the dead bone and at the same time to provide for adequate drainage after its removal. Simple curetting of an old sinus is a dangerous practice and if it is desired to clean up such a focus a free exposure of the field should be carried out by a formal operation. Tuberculosis. — Tuberculosis is a rare disease of the cranial bones and, although it does occur at any age, it is more frequent in children. It is usually secondary to a focus elsewhere in the body but may be primary, and in that case not infrequently follows an injury. Pathology. — The process starts in the bone and extends only second- arily to the soft parts. It frequently forms sequestra and perforates through the entire thickness of the bone, and the inner table is involved to a greater extent than the outer. The cavity in which the sequestrum lies is lined by tuberculous granulation tissue. There may be several such foci. Koenig has described a diffuse infiltration of the skull by tuberculosis without sequestrum formation. It is very rare. Symptoms. — The disease often, though not always, commences with pain in the head, severe in character and much worse at night. There is pain on pressure over the limited area involved in the process, and soon after the onset there appears a swelling. This is at first tender and firm, but sooner or later may soften and fluctuate, especially in the centre. This may pulsate and it may be reducible on pressure. After a variable length of time the overlying skin becomes thinned and ulcerates with a discharge of characteristic tuberculous pus. There is then established a tuberculous ulcer or a sinus lined with tuberculous tissue and leading down to bare diseased bone, often a sequestrum. This may persist for a long time, as the disease runs a very slow course. Treatment. — Treatment should consist in the complete removal by operation of all the tuberculous tissue, and the healing must take place by second intention. Syphilis. — Syphilis of the cranial bones is not a common manifesta- tion of the disease. It may follow the hereditary or acquired form. During the secondary stage the skull is a frequent site for the very painful circumscribed swellings of the periosteum which do not break down and readily yield to antisyphilitic treatment. During the tertiary stage there develop the gummatous processes which cause profound 344 INJURIES AND DISEASES OF HEAD AND BRAIN changes in the bone, resulting according to Dieulafoy, in two types, the perforating and the hypertrophic. Pathology. — The perforating form is not an unusual manifestation and is due to a deposit of gummatous tissue in the periosteum or dura mater, and results in an absorption of the bone due to a rarefying osteitis. A perforation of the cranium may occur. Side by side with this process and in a portion of the bone immediately next there may occur a growth of new bone which is denser than normal. The hypertrophic form results in the production of new bone over circumscribed areas. These areas may coalesce and give the appearance of a diffuse thickening. Symptoms.— Symptoms will differ, according to Dieulafoy, whether the process is on the external or internal surface of the skull. The pain in the head, worse at night, is a constant symptom in both form-. In the external or pericranial form a swelling soon appears which is adherent to the bone, over which the skin is movable at first, and which is firm and tender. Soon this softens and breaks down, giving rise to a characteristic syphilitic ulcer. In the internal or endocranial variety, on the other hand, there is no visible change in the contour of the skull. These swellings may, if they attain sufficient size, give rise to symptoms referable to pressure on the central nervous system, either those of irritation or paralysis. Treatment. — Treatment should be antisyphilitic and the prognosis is good. When sequestra have formed which are inclosed by an involucrum, an operative removal will be necessary to insure a com- plete healing and recovery. THE BRAIN. Injuries and diseases of the brain result, as in other organs, in stimulating or paralyzing its various functions. The brain, so often considered as a single organ, is in reality a collection of organs which differ from one another both in structure and function to as great a degree as, for instance, do the organs in the abdomen; and the central nervous system is in reality a system of organs in the true sense of that term. The fact that these organs in the brain are more intimately bound up with one another has given rise to the frequent misconception that the brain is a single organ. It is through an exact knowledge of the functions of these different cerebral organs, or constituent parts of the nervous system, that we are enabled to deter- mine the site of any given lesion of the central nervous system. There are many functions of these organs of which we are quite ignorant, and so oftentimes we are unable to located exactly the site of a given lesion, although we may know that the affection must be situated somewhere within the brain. The nature of the nerve impulse, which is the result or product of the activity of the nervous tissue, is itself 77/ a: BRAIN 345 not understood and we can judge of any disarrangement of this nerve impulse, whether qualitative or quantitative, only by noting a change in the function of some other tissue, which reacts in a certain manner as a result of a given nerve impulse. For example, the impairment of nerve impulse in a motor nerve can only be determined by examining the function of the muscle or muscles supplied by that nerve, and not by directly examining the nerve impulse, which we cannot measure and the very nature of which we do not know. The nervous tissue of the brain is composed of the neurones, the nerve cell and its axis-cylinder process, and the neuroglia or supporting stroma, which binds the numerous neurones together. This is richly supplied with bloodvessels and within its interstices there is a certain amount of cerebrospinal fluid and lymph. The function of the neurone, or the nerve impulse' may be interfered with either by severing the connection between the end organ and the nerve cell so that the nerve impulse does not reach the end organ, or by interfering with the function of the nerve cell by which the nature of the nerve impulse is altered either in quality or quantity. This may be accomplished by destruction of the constituents of the neurone, either cell or axis cylinder, or by interfering with their nutrition to such a degree that they either do not functionate normally or cease to functionate entirely. Therefore the symptoms of a lesion in the brain result from either a destruction of brain tissue or an interference with its nutrition, and the symptoms from one cause may not differ from those of the other. Depending on the degree of interference in the nutrition, however, we find that there is a great difference in the resulting symptoms, and we distinguish the irritative and paralytic type of symptom. By the term irritative symptom is meant the reaction which takes place as the direct result of a nerve impulse set in motion by an abnor- mal stimulus. The stimulus may be abnormal in quality, as electrical stimulation of motor cortex, or in quantity, as the stimulation of the respiratory centre by insufficiently oxygenated blood, or in both quality and quantity, as the stimulation by the presence of pus in the meninges. By the term paralytic symptom is meant the failure to obtain a reaction, as great in amount as normal, from a given stimulus. The neurones depend on a constant supply of well oxygenated blood in order to functionate properly. On the withdrawal of this supply they cease immediately to send out impulses, although they may remain viable a long time after they cease to functionate; therefore the symptoms of cerebral lesions depend in great measure on the disturbances of the circulation of the blood in the brain. Cerebral localization, or what is a better term, the functions of the various organs of the central nervous system, may be conveniently taken up by following the anatomical divisions of the brain which are familiar to all. A. Cortex of Cerebral Hemisphere is composed of portions which differ from one another histologically in structure and physiologically 346 INJURIES AND DISEASES OF HEAD AND BRAIN in function. Figs. 175 and 176 show the portions of the cortex whose function is known. Both are adapted from Campbell. Fig. 175. — Lateral aspect of brain. (After Campbell.) I. Precentral or Motor Area. — The area of voluntary muscular move- ment is situated in the posterior two-thirds of the ascending frontal convolution and the anterior boundary of the Rolandic fissure, infe- Fig 176. — Mesial aspect of brain. (After Campbell.) riorily almost, but not quite, to its lower end; on the mesial surface a small area anterior to the Rolandic fissure, on the paracentral lobule. THE BRAIN 347 The portions of the body controlled by this area are from above downward, foot, ankle, leu', knee and thigh; trunk; shoulder, arm elbow, forearm, wrist, and hand; face, lips, tongue, larynx and palate. II. Intermediate Precentral Area is the area controlling skilled or complex movements of an associated kind. Posteriorly it immediately joins the precentral area and extends forward on the paracentral lobule to the posterior portion of marginal gyrus, limited below by the callosomarginal fissure, while on the lateral surface it extends forward on the superior frontal gyrus, posterior end of middle frontal gyrus, and extending forward to include almost the entire inferior frontal gyrus, including part of pars basil aris, all of pars triangularis and the pars orbitalis up to transverse orbital sulcus. The skilled movements of an associated kind are the centre of motor speech, "Broca's centre" in the inferior frontal convolution on left side; cheirographic centre, in the middle frontal gyrus, that is, the region contiguous to the portion of the precentral area which controls voluntary muscular movements of the hands. In general there is in the intermediate precentral area a sequential disposition of centres for the control of higher evolutionary movements, following the same order from above downward as that observed in the precentral area proper. III. Postcentral Area is the "arrival platform" for the reception of sensory stimuli which have travelled up from the periphery. That is, it is the centre of common sensation. Anteriorly it extends from the precentral area in the fissure of Rolando to the midline of the postcentral gyrus on the lateral surface of the hemisphere, while on the mesial surface it extends on the paracentral lobnle backward from the fissure of Rolando. IV. Intermediate Postcentral Area is the region where there occurs the elaboration of the crude sensory impulses and the differentiation of them into the various kinds of sensation. On the mesial surface it joins the intermediate precentral area on the paracentral lobule and extends backward to the callosomarginal fissure, on the lateral surface it extends backward to the sulcus postcentrals superior and inferior. V. Visuosensory Areas in each hemisphere receive the primary im- pressions from the homonymous halves of the retinal fields. The area extends on either side of the posterior part of calcarine fissure and on the lower wall of the portion of the fissure anterior to its junction with the parieto-occipital fissure. VI. Visuopsychic Area controls the interpretation and synthesising of the primary visual impressions. It is an area which surrounds the visuosensory region and thus occupies the cuneus portion of parietal and temporal lobes. MI. Auditosensory Area receives the primary simple auditory stimuli. It corresponds to the transverse temporal gyri of Heschl. VIII . Auditopsychic Area interprets the primary auditory stimuli and occupies the posterior three-fifths of the superior temporal convolution. 348 INJURIES AND DISEASES OF HEAD AND BRAIN IX. Olfactory Area, which is the seat of the sense of smell, is limited to the gyrus hippocampus. B. Corpus Callosum. — Lesions in the corpus callosum give rise to apraxia. This occurs on left side in right-handed people and vice versa. Apraxia is the inability of a patient to carry out from memory a designated act, as the use of a hammer or a saw. When this loss is incomplete it is spoken of as dyspraxia. C. Optic Thalamus. — Lesions in the thalamus give symptoms only when situated in the posterior portion. They are often associated with lesions of the optic radiation. The thalamic syndrome consists of a moderate hemianesthesia and hemiparesis. This latter is not asso- ciated with contracture. There is, however, a persistent exaggeration of the reflexes. There is also a hemiataxia and hemiasteriognosis. On the side affected there may be constant pain and paresthesia, chorioid and athetoid movements are common. Painful stimuli, as pin pricks, give rise to greater discomfort than on the normal side. D. Midbrain. — Lesions near the corpora quadrigemina and crura cerebri give rise to visual disturbances, as loss of acuteness of vision and paresis of the associated ocular muscles; paresthesia on both sides of body and ataxia of extremities is frequent. At times choreo-athetoid movements develop and there may be a contralateral diminution of hearing. There may be hemiplegia on the side opposite to the lesion, hemi- anesthesia on the side of the lesion, together with an ophthalmoplegia on the side of the lesion (involvement of motor occuli nucleus). E. Cerebellum. — Lesions of the cerebellum may have definite focal signs, among them the following should be mentioned : Cerebellar ataxia causes a staggering similiar to the gait of a man intoxicated by alcohol. There is an asynergia, that is, a tendency to incoordination between the action of the muscles of the trunk and of the lower extremities, whereby the trunk may remain stationary while the legs move forward, or the legs stop walking and the trunk continues to move forward. There is also a tendency to fall toward the side of the lesion if in the hemispheres, to fall backward or forward if in the central vermes. In severe cases patients are not able to remain erect. Dizziness is a true rotatory dizziness, the patient feels as if he were turning over or that objects about him were going round. This is usually associated with nystagmus. Nystagmus is frequently present, but may be observed in lesions elsewhere than in the cerebellum. It is most pronounced with the eyes in an extreme lateral position, and then most marked in the abducted eye. The movements, especially of the upper extremity, are often ataxic and there may even be an intention tremor. F. Pons. — Lesions of the pons result in a paralysis of the facial muscles and of the extremities on the same side. This occurs from lesions in the upper level of the pons before facial fibres decussate. CRANIAL TOPOGRAPHY 349 In the lower level of the pons below decussation of facial fibres there will be paralysis of face on the side of lesion and of limbs on the side opposite to lesion, alternate paralysis. Sensory disturbances may occur if lesion is in tegmentum. G. Medulla Oblongata. — Lesions here are mainly pyramidal lesions with a crossed glossopharyngeal, vagal, and hypoglossal hemiplegia. CRANIAL TOPOGRAPHY. To guide the surgeons in opening the skull to attack lesions in certain definite locations, the relation of the chief fissures and convolutions to certain external landmarks is important. By determining the position of the fissure of Rolando, the fissure of Sylvius, and the parieto-occipital fissure, one can locate with reasonable accuracy any of the well-known cortical centres. To locate the fissure of Rolando, measure the distance from the glabella to the external occipital protuberance, mark a point one-third of an inch behind the centre of this line, and from this point draw a line obliquely downward and forward three and a half inches in length at an angle of 67 degrees with the median line. To locate the fissure of Sylvius, draw a line from the lower margin of the orbit backward through the centre of the external auditory meatus; draw a second line parallel with this from the external angular process of the frontal bone backward for a distance of an inch and a quarter; make a mark one-quarter of an inch above this point. Next find the most prominent portion of the parietal eminence, and make a second mark three- quarters of an inch below this eminence; a line connecting these two points will lie directly over the fissure of Sylvius. To find the parieto- occipital fissure, continue the line of the fissure of Sylvius backward until it intersects the median line. The fissure lies immediately beneath the junction of these two lines. The lower margin of the occipital lobe and the attachment of the tentorium will be indicated by a line drawn from the upper margin of the external auditory meatus to the occipital protuberance. The cerebellum lies below this line. The lateral sinus extends along this line from the occipital protuberance forward to a point one inch behind the meatus; it then passes downward toward the mastoid process. The main trunk of the middle meningeal artery lies at a point an inch and three-quarters above the zygoma and an inch and a half behind the external angular process of the parietal bone. Charles K. Mills, in 1902, from the facts then available regarding cerebral localization and cranial topography, published a paper giving seven lateral cranial areas for osteoplastic operations, with syndromes for each region. A glance at Figs. 177 and 178 will give a general idea of the principal well-established areas. These areas are shown in Fig. 179 and the corresponding syndromes quoted from his original article. 350 INJURIES AND DISEASES OF HEAD AND BRAIN In each case the symptoms of irritation or destruction of the region are given first, afterward those of advancing pressure. CONCRETE CONCEPT Fig. 177. — Side view of human brain, showing localization of functions. (Charles K. Mills.) Fig. 178. — View of the mesial surface of the human brain, showing localization of functions. (Charles K. Mills.) A. Higher Psychical Area. — Interference with higher psychical processes as shown in lack of power of sustained attention, impairment CRANIAL TOPOGRAPHY 351 of the faculties of reason, comparison and judgment; mental obtuse- ness; relative optimism; sometimes mild hallucinations and delusions. Among the most likely compression and invasion symptoms are motor agraphia, motor aphasia, monoplegia or hemiplegia. On the negative side are absence of anesthesia, cutaneous or muscular; astereognosis, hemianopsia, word blindness, word deafness, and paraphasia. B. Motor Speech Area. — Motor aphasia, usually associated with some motor agraphia, and paresis, especially of the face. More complete hemiplegia may indicate compression or invasion, as may also some psychical disturbance. On the negative side absence of the same symptoms as given for area A. C. Motor Area. — Monoplegia or hemiplegia, spasms usually begin- ning in one limb or in one side of the face, and usually either confined or more marked in the half of the body opposite to the side of the lesion. Fig. 179 Tonic spasticity is usually present, and both the superficial and deep reflexes are much exaggerated, persistent ankle clonus and the Babinski response being present. Motor aphasia and agraphia may be com- pression and invasion symptoms when the tumor spreads cephalad, or affections of cutaneous and muscular sensibility and astereognosis when it increases caudad. Psychical symptoms, except those due to general cerebral irritation and visual and auditory symptoms, are usually absent. D. The Stereognostic Area. — Astereognosis and hemiataxia, im- pairment of muscular sensibility and of cutaneous sensibility; the superficial reflexes usually impaired; the Babinski response not present, but the normal metatarsophalangeal response often absent, that is, the toes not moving from irritation of the sole of the foot; the deep reflexes practically normal. Frequent compression and invasion symptoms are gradually augmenting hemiparesis, gradually increasing 352 INJURIES AND DISEASES OF HEAD AND BRAIN reflexes up to the point of exaggeration, and hemianopsia. Higher physical symptoms absent and aphasias usually absent; sensory aphasia present at times when the tumor spreads backward and downward. E. The Auditory Area. — Word deafness, partial or complete; verbal amnesia and paraphasia. Compression and invasion symptoms may be paresis or paralysis; visual symptoms, such as word blindness and hemianopsia, and impairment of cutaneous and muscular sensi- bility. Reflexes usually not much altered. Higher psychical symp- toms, motor agraphia, motor aphasia, and astereognosis usually absent. F. The Higher Visual Area. — Word and letter blindness and verbal amnesia. Compression and invasion symptoms, chiefly auditory symptoms and hemianopsia, although astereognosis, ataxia, and motor disturbances may be present. The Wernicke reaction, motor disorders, and higher psychical disturbances are usually absent; and the deep and superficial reflexes in the extremities are usually not altered. The superficial reflexes are most likely to be impaired, owing to the anesthesia. G. The Lower Cortical Visual Area. — Hemianopsia often associated with forms of word blindness when the tumor is of considerable size; other localizing phenomena usually absent. INJURIES OF THE BRAIN. Concussion.— Concussion of the brain may be defined as a condition of impaired or suspended cerebral function, resulting in a loss of consciousness, temporary or prolonged, due to a sudden and violent jarring of the brain. The cause of this condition may be a fall or a blow on the head, with or without fracture, or a fall upon the buttocks, the force being transmitted through the vertebral column. Many theories have been propounded to account for the symptoms of con- cussion. Recent investigations, however, show that in pure concussion the only structural change may be a condition of shrinkage, changed outline and chromatolysis of the ganglion cells, similar to that produced by exhaustion or starvation. Symptoms. — The symptoms of concussion vary greatly in degree. As a rule, they are most pronounced immediately following the injury and progressively improve. An example of the simplest form would be the slight giddiness and visual disturbance commonly spoken of as "seeing stars," which one frequently experiences for a moment after a sudden blow on the head. A more severe type would be illustrated by the sudden suspended consciousness and complete muscular relaxation which follow a "knock-out" blow on the angle of the jaw. Recovery from such a blow usually takes place in a few seconds, but for several minutes thereafter the individual seems dazed and not quite in touch with his surroundings. Later a feeling of weakness and INJURIES OF THE BRAIN 353 indisposition to physical or mental exertion may be present for several hours. We may thus distinguish two groups, the mild and the severe cases. Mild Cases. — Following a blow or fall there supervenes unconscious- ness accompanied or preceded by dizziness; the patient sees stars before the eyes or has a ringing in the ears. There then follows a weakness in the knees and other muscles; the arms fall loose at the sides, the face becomes pale, the look is fixed and expressionless and the eyelids close. The respirations are so shallow that it seems as though the person was not breathing at all; the pulse is small, thready and usually slow. In the mild cases this condition does not last long; the pulse becomes fuller, there are several deep breaths, the patient opens the eyes, stretches out his arms, stands up. In walking he may be a trifle unsteady in his gait, complain of headache, ringing in the ears and extreme weariness and lassitude. This gradually becomes better and in a short time the patient returns to work. Severe Cases. — At the moment of the blow or fall the patient crumples up and remains unconscious and motionless. It is not possible to awaken him. He does not react to corneal reflex or to skin irritation or stimulation. The pupil, which is at times contracted, at times dilated, reacts to bright light, and when water is placed in the mouth it is swallowed. The face is pale. The surface of the body and the extremities are cold. The respirations are irregular and every now and then will occur a deep, long-drawn sigh. The pulse is small, somewhat irregular, usually, but not always, slow. There may be involuntary urination and defecation. Vomiting may occur several times immediately following the injury. Finally the respiration becomes deeper, the pulse becomes fuller and stronger. The body becomes warm and motion returns. The patient may remain in this condition for hours or even days, with complete loss of consciousness. He then becomes restless and finally regains consciousness. He may answer questions correctly, but all recollection of the injury or events immediately preceding it may be lost, never to be regained. At times he may have forgotten events several days preceding the injury. There now follows a stage of exaltation. The pulse is frequent and hard, the temperature is raised, the face is flushed, the pupils contracted. The patient complains of headache, restlessness and pains in the limbs. This stage may last a variable time. The longer the symptoms last the greater is the possibility that other lesions have occurred. Diagnosis. — Only in the cases in which improvement supervenes rapidly, when the patient recovers shortly after the injury, can we speak with any assurance of a pure concussion. In the severe cases the diagnosis must be tentative at first because of the frequent occur- rence that other lesions are present or may supervene, as compression, contusion or meningitis. 23 354 INJURIES AND DISEASES OF HEAD AND BRAIN Concussion alone never causes a gradual increase in the severity of the symptoms after the onset, as deepening of the coma, continued slowing of the pulse, convulsive movements, convulsions or paralysis. Treatment. — A patient who has had a mild concussion probably will require no treatment, although he may complain of some muscular weakness for several days. Severe cases should be kept in bed, with the head lowered. The application of external warmth is indicated, and if he can swallow, small quantities of fluid nourishment. Cathar- tics should be given to insure a free movement from the bowels each day. A period of prolonged unconsciousness should make one examine carefully for other possible conditions. Compression of the Brain. — Normally the cavity of the skull is completely filled by nervous tissue, the brain and the cranial nerves, by the bloodvessels filled with blood, arteries, veins and capillaries, and by the cerebrospinal fluid, contained in the subarachnoid space and the ventricles of the brain. As a substance each one of these elements is as non-compressible as water. The brain is a vascular structure, well supplied by arteries with a rich capillary network, drain- ing into numerous large veins, which empty into the sinuses of the dura mater. It is surrounded by cerebrospinal fluid and may be said to float in a water-bed within the cranial cavity. By the term compres- sion of the brain is meant that the bloodvessels in the nervous tissue are compressed and emptied of their contents, whereby the circulation within them is deranged and there results an interference with the nutrition of various portions of the brain, particularly in regard to the supply of oxygen. Thus compression of the brain is solely a manifesta- tion of a circulatory disturbance in the brain. This disturbance may be a local one confined to a limited area, or a general one resulting in more or less complete asphyxiation of the entire brain. In local pressure the interference with the circulation is most marked in the immediate vicinity of the compressing agent, and there is about this an ever widening area, showing a progressively diminishing degree of circulatory derangement. In general pressure, the entire brain being involved, the oxygenation of the vital centres grouped in the medulla is interfered with. As soon as the vasomotor centre feels the effect of asphyxiation it sends out impulses which raise the general arterial pressure, in the endeavor to overcome the force compressing its blood- vessels and so diminishing its supply of oxygenated blood. The high blood-pressure does not remain at a fixed level but varies in rhythmic waves (Traube-Herring waves), and when the intracranial tension becomes so great that the blood-pressure variations rise above and fall below its level, there result periods of anemia at the lowest point of the wave, followed by periods of oxygenation at the crest of the wave. During the period of anemia the respiratory centre ceases to functionate, the respiratory act ceases, to recommence when it is again supplied with blood. This gives rise to the Cheyne-Stokes type of respiratory rhythm. PLATE XII Emissary vi in 1 / it mis lacuna \ _ Sup. sagittal sinus \ Cerebral vein Diploic vein \ Arachnoid granulation Meningeal vein Subdural cavity Subarachnoid cavity a mater Arachnoid Cerebral cortex Diagrammatic Representation of a Section Across the Top of the Skull, Showing the Membranes of the Brain, etc. (Modified from Testut.) INJURIES OF THE BRAIN 355 For clinical purposes we can conveniently divide the symptoms into four stages (Kocher, Ciishing). First stage, or stage of compensation corresponds to a mild degree of pressure resulting in a squeezing out of the cerebrospinal fluid from the immediate neighborhood of the compressing force, a slight inter- ference in the venous return giving rise to a moderate venous congestion. The symptoms are often imperceptible, a mild degree of headache, some slight mental dulness and at times symptoms referable to the site of the lesion in the brain. These latter will be irritative in character. Second stage, or stage of beginning evident pressure, is coincident with an impaired circulation over an extended area whereby there is a pronounced venous stasis. There is a certain degree of vertigo and restlessness accompanied by a severe headache. The pulse is often slow from stimulation of the vagus. As pressure continues the sensorium is affected and delirium develops. There may or may not be a papiledema and a slight rise in general blood-pressure. The optic disk shows a tortuosity of the veins. At times there is a con- gestion of the face. Third stage, or stage of pronounced pressure. Here the pressure has increased sufficiently to empty the capillaries and give rise to an extended capillary anemia which is intermittent because of the fluctua- tions in the blood-pressure. The vasomotor and other centres in the medulla are affected. The rhythmic fluctuations in the heightened blood-pressure give rise to the Cheyne-Stokes respiratory rhythm, variations in the size of the pupils and restlessness alternating with stupor. The patient is more restless during the high point in the blood- pressure curve and at the same time the respiratory act occurs. The pulse is slow, 50 or below, full, bounding in character. The face is congested and not infrequently becomes cyanotic. There is a pro- nounced degree of choked disk. The stupor and coma become more profound, the reflexes are abolished and the compensatory factors of vasomotor impulse begin to fail. Fourth stage, or stage of paralysis follows the last, at times with alarming rapidity, at others more gradually. The vasomotor centre suffers with the others; its efforts at compensation fail, the blood- pressure falls, the pulse becomes rapid, irregular and small, the coma deepens, general muscular tone vanishes with complete relaxation, the cerebral functions cease and patient dies from respiratory paralysis. Prognosis. — The prognosis is always grave. The causative factor, the rapidity in the development of the symptoms and the degree to which they have advanced, will influence materially the ultimate outcome. Each case must be considered on its merits, but those cases in which the failure in compensation has appeared are especially serious and frequently do not recover even with appropriate treatment. Treatment. — One should not delay in relieving this condition until there are symptoms of beginning paralysis of the medulla centres. The pulse-rate, choked disk, and blood-pressure are criteria of greatest 356 INJURIES AND DISEASES OF HEAD AND BRAIN importance. The relief must be attained by operation. A craniotomy to relieve the pressure is indicated. A choice of the site for the opening in the skull must be determined by the probable site of the cause of the compression. The subtemporal decompression offers the most useful operation when the site of the lesion cannot be determined as the resulting deformity and the danger of subsequent hernia is diminished. Contusion and Laceration of the Brain. — Contusion of the brain is synonymous with laceration of the brain and intracerebral hemorrhage. There occur varying degrees of destruction of brain tissue. It may be the direct result of trauma, or of the spontaneous rupture of a blood- vessel. This latter has, up to the present time, very little interest for the surgeon. The destruction from trauma may be directly beneath the point of injury to the skull or may be at a distant point. At times it occurs at the opposite pole to that struck. A frequent site is the tip of the temporal lobe or base of the frontal lobes. Symptoms. — There usually occur the signs of a concussion, which instead of clearing up promptly, continue, or even increase in intensity, with a febrile movement after a few days. A lumbar puncture will often reveal the presence of blood in cerebrospinal fluid. Convalescence is prolonged, accompanied by more or less persistent severe headache, restlessness and irritability. It may require several months for a patient to completely recover and be restored to health so that he is able to carry on hard mental work. A severe laceration of the brain may be followed by permanent changes in a patient's character, or may result in an impairment of his mental vigor. At times it is followed by Jacksonian epilepsy. Prognosis. — A guarded prognosis as to ultimate results should be given in every case of brain laceration. Treatment.— Patient must be confined to bed until the fever has subsided and until all symptoms of an active process have disappeared. He should not be allowed to return to work for several weeks, or until he is free from headache and has regained his lost flesh and strength. The occurrence of compression symptoms may demand a decompressive operation for their relief. INTRACRANIAL HEMORRHAGE. These may be classified according to the situation in which the extravasated blood is found: (1) extradural; (2) subdural; (3) pial; (4) subpial; (5) intracerebral. 1. Extradural Hemorrhage. — The extravasated blood is situated between the skull and the dura mater. It is not a common lesion in its pure form, and yet not by any means a rarity. It is rare in children or infants. Pathology. — It is always due to injury. The blood accumulates between the dura mater and the skull. The blood may come from the INTRACRANIAL HEMORRHAGE 357 middle meningeal artery, venous sinuses, or diploic veins. The anterior branch of the middle meningeal is by far the most frequent source, less frequently its main trunk, or its posterior branch, and least of all, its middle branch. The venous sinuses are occasionally, but not frequently, the cause of extradural hemorrhage. The superior longi- tudinal is the most frequently injured; then the transverse, most often at the point of junction between its transverse and the vertical portions. The diploic veins are rarely the cause of this lesion. The train of symptoms depends largely on the anatomical peculiarity that the dura is firmly adherent to the bone and separates only very slowly as it is dissected away by the extravasated blood. The blood clot is apt to be lens shaped. Trauma always causes it and the lesion usually is a fractured skull. Symptoms. — There is a history of injury which is followed by more or less pronounced concussion with its attendant symptoms. The patient may completely recover from the concussion, and have what is spoken of as a free interval, during which time he may be absolutely free from symptoms. During the free interval he may not completely clear up, and he may, even before he again loses consciousness, develop focal symptoms which would locate the site at which the extravasation is taking place. In injury to the middle meningeal, there will develop oftentimes irritative or paralytic symptoms of the lower end of pre- central area in face and arm, while on the left side there may be motor aphasia. After a variable space of time he will complain of headache, nausea, vomiting; and rapidly passes into a state of increased intra- cranial pressure and may pass through all of its four stages. There may be focal symptoms referable to the cortex. These at first may be irritative and later be paralytic, or they may be paralytic from the beginning. The rapidity with which the blood accumulates will determine the duration of the free interval and also the train of the symptoms of intracranial pressure. Diagnosis.— Diagnosis will be made by a history of injury which may or may not be followed by unconsciousness (concussion), from which the patient recovers; he then has an interval during which he is free from symptoms, and later develops increasing symptoms of compression. Treatment. — This should consist, in every case in which the diagnosis of extradural hemorrhage can be established, in operative interference, removal of the blood clot and ligation of the vessel if necessary. In doubtful cases in which the diagnosis is probable, exploration 'also offers the best chance. The determination of the point at which the opening should be made, in many cases will be readily reached, in others it may be difficult, and it is then justifiable to explore one side and, if no evidence of injury is found, immediately to explore the other. The operative procedure should consist in an exploratory craniotomy, after determining the probable site of the lesion, whether at the point of injury or in the opposite hemisphere in the case of bursting or bend- 358 INJURIES AND DISEASES OF HEAD AND BRAIN ing fractures, and in the hemorrhages from the middle meningeal artery, entering the skull at the pterion for anterior branch, centre of squamous of temporal for middle branch, postero-inferior angle of parietal for posterior branch. 2. Subdural Hemorrhage. — The extravasated blood is situated beneath the dura mater in the meshes of the arachnoid space. It is more frequent than the extradural hemorrhage and may occur at any age. It is not always preceded by trauma. Any injury to the pial vessels, sinuses of the dura mater, fracture of skull, especially through the base with rupture of dura, will result in the extravasation of the blood in the arachnoid space. This is usually a diffuse extravasation, in which the blood accumulates about the base. The blood spreads more rapidly in the arachnoid space than beneath the dura and although it may clot, it does so more slowly. The cerebrospinal fluid is blood tinged even down in the spinal canal. Symptoms. — Symptoms as a rule are those of more or less rapidly occurring, increased, intracranial pressure. At times there may intervene a free interval. This is certainly rare. The cerebrospinal fluid obtained by lumbar puncture will show presence of red blood cells. Treatment. — Treatment must be governed entirely by the course of the intracranial pressure. If, as in man}' cases, this reaches a certain degree compatible with life and remains stationary, the treat- ment should be expectant, but in the cases in which the intracranial pressure steadily increases, one should not wait for alarming symptoms of failure at compensation before he decompresses to relieve the embarrassed medullary centres. 3. Pial Hemorrhage. — Pial hemorrhage occurs when the blood is extravasated between the two layers of the pia mater. It disseminates widely and rapidly. It is seen frequently during operative procedure when the cortex is handled roughly. It gives to the surface of the brain a peculiar light cherry-red color. Not infrequently it is seen as a peripheral zone about an area of contusion and laceration. 4. Subpial Hemorrhage. — Subpial hemorrhage is where the blood separates the pia mater from the surface of the brain. The blood often remains fluid, is disseminated over a limited area, and never accumulates in any great quantity to form a thick layer. 5. Intracerebral Hemorrhage. — Intracerebral hemorrhage, as has been stated, is closely allied to the contusion and laceration of the brain. The hemorrhages may be the result of a rupture of a diseased vessel, or of an injury. The extravasation occurs within the cerebral sub- stance, and, depending upon the rapidity of its accumulation, will appear an encapsulated blood clot, or simply a diffuse infiltration. At times the blood flows into and fills the ventricles. Symptoms. — A typical case of spontaneous intracerebral hemorrhage from rupture of some diseased vessel, the stroke of apoplexy, will be familiar to all; the sudden loss of consciousness, the alarming failure of cardiac and respiratory centres leading to death in the severe cases, DISEASES OF THE BRAIN 359 the slow gradual recovery with the resulting hemiplegia phenomena in the cases which recover. In left-sided lesions the mental vigor of the patients is more apt to remain impaired. In the traumatic cases the symptoms and treatment do not in any way differ from those of contusion or laceration of the brain. DISEASES OF THE BRAIN. Septic Inflammation of the Brain and its Membranes. — Infection of the intracranial structures may take place through an open wound, by the bloodvessels, or by the lymphatics. The commonest cause is trauma; the others, in the order of their frequency, are middle-ear disease, disease of the frontal sinuses or ethmoidal cells, suppurative lesions of the scalp, and metastases from other remote septic foci. In fractures at the base of the skull the infection generally takes place through a fissure which communicates with the nasal, pharyngeal, or aural cavity. In compound fractures of the convexity infection is often carried inward by hairs or bits of clothing driven in by the fracturing force. In middle-ear disease and inflammations of the accessory nasal sinuses, infection is usually carried by direct extension (necrosis of bone) or through the lymphatic or venous channels. In traumatic cases, in which general infection occurs, and in many cases of spreading infection from local causes, the inflammatory process involves all of the intracranial structures, meninges, brain substance, sinuses, and nerve trunks. In these cases it is often impossible to distinguish clinically between the different lesions, the symptom- complex suggesting only a diffuse septic inflammation which leads rapidly to a fatal termination. In milder infections which spread less rapidly one is often able to make a more specialized diagnosis. These infections may be classified by the exact situation of the inflam- mation, whether in dura mater, pia mater or brain. Meningitis. — Two forms of meningitis occur: pachymeningitis, or inflammation of the dura, and leptomeningitis, or inflammation of the pia. Acute External Pachymeningitis. — Acute external pachymeningitis is an inflammatory process situated between the inner surface of the skull and the dura mater. It is usually the result of compound fracture of the skull which has not wounded the dura. When such a wound becomes infected, which often occurs from tightly closing a scalp wound without drainage, a collection of pus forms on the outer surface of the dura which may extend for a considerable distance, separating the dura from the skull and giving rise to a tumor which causes symp- toms of local brain-pressure. It may arise from a slow chronic or subacute, distinctly localized process of inflammation on a portion of the inner table of the skull. The infection may have begun on the outer table. The disease is recognized by pain, throbbing, edema of the scalp, headache, evidences of septic intoxication, and possibly 3G0 INJURIES AND DISEASES OF HEAD AND BRAIN focal brain symptoms. Opening the wound, removing a button of bone, evacuating the pus, irrigation and drainage of the cavity will usually result in a cure, unless the infection is carried by the dura] veins to one of the sinuses, in which case sinus thrombosis and pyemia may develop. Chronic Internal Pachymeningitis. — Chronic internal pachymeningitis is a rare condition, the etiology of which is obscure. It is characterized by a localized plastic inflammation occurring on the inner surface of the dura. The plastic exudate becomes highly vascular; hemorrhages may occur, giving rise to symptoms of local or general compression. The process is an extremely slow one, is rarely diagnosticated, and has not received the attention from surgeons which its importance merits. Munro, of Boston, has demonstrated that surgical relief is sometimes possible. The symptoms are, as a rule, chronic headache with occa- sionally well-marked focal brain symptoms. The treatment should be an exploratory osteoplastic resection of the skull, with removal of the clots and exudate, and subsequent closure of the wound. Acute Septic Leptomeningitis. — This is the usual form of meningitis which occurs after trauma and from extension of a septic process from a neighboring focus. It occurs also as an epidemic disease — cere- brospinal meningitis — and as a tuberculous process. It is, however, only with the septic form that the surgeon has to deal. Following an external pachymeningitis an adhesive inflammation occurs which glues together the structures immediately beneath it, namely, the arachnoid, pia and brain, and thus a local leptomeningitis may develop. When this inflammation continues and there occurs a softening process, a collection of pus may form within the meshes of the arachnoid giving rise to what is spoken of at times as a subdural abscess. If on the other hand the infection is brought directly to the pia mater by a penetrating wound or the inflammatory process extends very rapidly before any adhesions can take place, there occurs a generalized lepto- meningitis. Pyogenic infections of the face and scalp, as erysipelas, furuncle or carbuncle may give rise to leptomeningitis. In this case the infection usually travels by a thrombosis of the diploic veins and so gains access to meninges. Septic meningitis may begin in the pia covering the convexity of the brain or at the base. In either case the process extends rapidly and eventually involves the greater part of the membrane, including that portion lining the ventricles. The surface of the brain is injected, edematous, and covered with fibrin; the cerebrospinal fluid is at first cloudy, but later becomes distinctly purulent and distends the subarachnoid space and ventricles, causing marked pressure on the brain-substance. Symirtoms. — The symptoms at first are those of cortical irritation — severe headache, with intolerance of light and sound, fever, chills, a rapid pulse, and stiffness of the muscles of the neck. The pupils are contracted; there are wild delirium, spasmodic contraction of the muscles, and occasionally general convulsions. As the disease DISEASES OF THE BUMS 361 progresses the irritative symptoms gradually give way to those of paralysis of the cortical centres. There is stupor, the delirium becomes low and muttering, the pupils dilate, and symptoms of cerebral compression appear. In meningitis limited to the region of the base, the early headache and delirium may be wanting; the symptoms are those of general sepsis and cerebral irritation, followed by paralysis of the cranial nerves and cerebral compression. In doubtful cases lumbar puncture may be practised, and the fluid withdrawn examined for pus and micro-organisms. Prognosis. — The prognosis is extremely grave. Death may occur at any time, from two to ten days from the onset of the symptoms. Treatment. — The /treatment should consist in rest in a darkened room, cold to the head, cathartics, low diet, and measures to control the early pain and delirium. The original wound, if one is present, should be enlarged and one or more other openings made in the skull for irrigation and drainage of the subdural space. This treatment thoroughly carried out has occasionally been followed by recovery. Ventricular drainage will sometimes be indicated. In the early stages of the infection, urotropin is to be recommended. Encephalitis. Acute encephalitis is a softening and inflammation of the brain tissue which has no well-defined limit-, surrounded by an area of edema which merges gradually into the normal brain. A compound fracture of the skull associated with laceration of the brain, which becomes infected, gives rise to it. Penetrating wounds in which the septic material is carried deep into the brain substance, a capillary thrombosis of the veins leading into the brain from a neighboring septic focus, also may cause it. Such a focus may be a pachymeningitis or an otitis media, acute or chronic, the last being a frequent cause, as the granulations slowly erode the bony walls of the middle ear and the way is opened for the entranceof micro-organisms intothecranialcavity. Symptoms. — The symptoms of acute encephalitis resemble those of an acute septic meningitis, or they may be less severe, and simply those of local cortical irritation followed by pressure-symptoms. These latter are largely due to the pronounced inflammatory edema which often results. The symptoms may gradually pass away and recovery take place. The termination of encephalitis may be in death from sepsis or the accompanying meningitis, in recovery, or in the development of an acute or chronic cerebral abscess. Treatment. — The treatment should consist in proper and adequate drainage of the infected focus. As abscess of the brain results most frequently from middle-ear disease; it is generally located in the temporosphenoidal lobe or in the cerebellum, the infection in the former instance taking place through the roof of the tympanum and antrum of the mastoid; in the latter through its posterior wall or from a sinus thrombosis. The location of abscesses in other silent regions may be suggested by scars and evidences of previous injury. 362 INJURIES AND DISEASES OF HEAD AND BRAIN Abscess of the Brain — Abscess of the brain results from an enceph- alitis which has become encapsulated. At first there is an exudation of serum and leukocytes together with a swelling of the brain tissue and often there is an extravasation of red blood cells which gives rise to what is spoken of as red softening. Soon there supervenes a soften- ing process as the brain tissue disintegrates and pus is formed. About the area of softening and pus there is at first a zone of acute inflamma- tion which shows a hyperemia of the vessels, edema of brain, and exudation of cells. The wall of such an abscess is covered by sloughs and exposed thrombosed vessels and is rough and shaggy with shreds of tissue hanging from its surface. An abscess often becomes encap- sulated when the molecular disintegration ceases and a capsule of fibrin forms about it which may in time become vascularized. Some cerebral abscesses may become absorbed, or slowly but progressively increase in size and rupture into the ventricles of the brain or subdural space. At times there is more than one abscess present. Symptoms. — There are a number of different courses which an abscess of the brain may pursue. McEwen has drawn attention to the fact that in cases which are said to be chronic, located in one of the silent areas of the brain and giving rise to no symptoms, one must be careful not to confuse symptoms not observed with symptoms not present. There are usually some signs if sought for properly. In the majority of cases there is a period during which there is headache of a very severe character, vomiting which is quite independent of the ingestion of food, chills and rigors of varying severity, slight rise of temperature with rapid pulse and pronounced degree of prostration. During this period the diagnosis of brain abscess usually is not made, this may last for one or several days and is followed by the period during which characteristic symptoms of cerebral abscess appear. There is some pain in the head and slight tenderness on percussion over the site of the disease. There develops a peculiar mental state as shown by slow cerebration during which the patient is asked a question and then waits a considerable interval before he answers, but then usually answers correctly. There is also a lack of sustained attention during which he may ask for a drink of water and then fall asleep before he receives it, or he may commence a long answer to some question only to lapse into slumber before he finishes it. He often lacks the power to use his strength, not so much from any physical weakness as from a loss of will-power to exert it. As time goes on his mental obscuration increases. His temperature is normal or even subnormal, his pulse is slow and full. Respirations are slow. There is apt to be a pro- nounced degree of constipation and a complete loss of appetite. The optic neuritis is a constant and pronounced symptom and as the disease progresses the patient becomes emaciated. Course.— If left untreated the case may terminate in several ways. Death may result gradually, preceded by stupor and coma with signs of brain compression or with symptoms of acute leptomeningitis, or DISEASES OF THE BRAIN 363 suddenly, due to the rupture of the abscess into the ventricle. McEwen divides cases of brain abscess into those which develop with complete latency, with subacute evolution, those similar to brain tumors and those of the remittent type in which there are exacerbations of severe symptoms followed by periods during which the symptoms are much ameliorated, if not entirely absent. Treatment. — When abscess of the brain is suspected, the skull should be opened by a large trephine or by the osteoplastic method, the dura incised, and the surface of the cortex examined for bulging, softening, or absence of pulsation. A grooved director should next be introduced in several directions, and when pus is reached the opening should be enlarged by introducing a pair of closed dressing- forceps and withdrawing them with the blades slightly separated. The cavity, if large, may then be explored by the finger, irrigated with salt solution, packed lightly with gauze, and the wound partly closed. During these manipulations the subdural space, unless it is closed by adhesions, is sure to be contaminated with the pus, and should be drained by pledgets of gauze introduced between the dura and sur- rounding cortex. The pus of chronic, long-standing brain abscesses, however, is likely to be sterile. The subsequent treatment should consist in cleanliness and frequent gentle packing of the cavity until it fills with granulations. Sinus Thrombosis. — Sinus thrombosis may arise in the marasmic state of the very young or very old or in those patients debilitated from disease, as typhoid fever, or it may be the result of trauma; but the most frequent form is that due to a septic inflammation of the walls of a sinus, the infection usually being brought to the sinus by a neighboring osteomyelitis, or septic thrombosis of one or more small tributary veins. The sinus becomes filled with a thrombus, which also becomes infected, and later may soften, disintegrate, and be carried by the circulation to any part of the body, giving rise to metastatic abscesses and pyemia. While any of the cerebral sinuses may become infected, the one most commonly diseased is the lateral sinus from extension of a septic process of the middle ear through the mastoid cells to its sigmoid portion. Next in frequency comes the cavernous sinus, from direct infection from the sphenoidal cells or from a septic thrombosis of the veins about the orbit or forehead. Throm- bosis of the longitudinal sinus or of the petrosal are rare. Symptoms. — The symptoms of infective thrombosis of the lateral sinus are usually preceded by a history of an acute exacerbation of an old middle-ear disease with tenderness over the mastoid and fever. Following this there is a severe constant localized pain, with marked elevation of temperature and a rapid, feeble pulse. The fever is marked by notable remissions; there may be chills and sweats. If the process extends to the jugular vein, there will be pain and induration over the region of the upper part of the jugular in the neck. If the cavernous sinus is involved, there will be exophthalmos and chemosis, 364 INJURIES AXD DISEASES OF HEAD AXD BRAIX with congestion of the lids and dilatation of the retinal veins. In advanced stages of sinus thrombosis evidences of involvement of the cranial nerves may be present. Thus in involvement of the lateral sinus and jugular vein, hoarseness, dysphagia, or paresis of the muscles supplied by the spinal accessory; in cavernous thrombosis, paralysis of the ocular muscles, hyperesthesia over the distribution of the trigeminus, or choked disk may be present. At a later period in the disease evidences of metastatic accidents manifest themselves, and the patient gradually succumbs to general septic infection. Treatment. — This should be undertaken at the earliest possible moment, and should consist in freely exposing the mastoid region by a curved incision back of the ear, supplemented if necessary by a horizontal incision at right angles to the first. The mastoid antrum and cells should be freely opened by a chisel or rongeur forceps, and the -inns located and opened. The clots should be gently removed first from the direction of the torcula and then from the jugular extremity until blood flows. The -inns should then be irrigated with salt solution, and packed with sterile gauze. If the thrombus extends well into the jugular vein, this should be ligated below the disease, opened, and if possible irrigated from above. The wound should then be partly closed, ample provision being made for drainage of the tympanum and mastoid antrum. Thrombosis of any of the other cerebral sinuses, if considerable, may be treated in the same manner; but, as a rule, the symptoms are obscure and the condition remains unrecognized until it is beyond the help of the surgeon. As stated above, in many of these cases of intracranial sepsis the surgeon is unable to make an exact diagnosis, as two or more of these processes may be present at the same time. In such cases the necessary operations are in the nature of exploratory procedures, the sub- sequent steps of the operation depending upon the pathologic lesions found. Hydrocephalus. — Hydrocephalus is an abnormal collection of fluid within the cranial cavity. In external hydrocephalus the fluid is in the subdural space, in internal hydrocephalus the fluid is in the ventricular cavity. The condition may be congenital or acquired. It is, however, surgically important only in infancy and childhood. In the congenital variety, which is usually internal, the ventricular distention may be due to some obstruction in the aqueduct of Sylvius which prevents the fluid secreted in the lateral ventricles from passing downward through the fourth ventricle and the foramen of Magendie into the subarachnoid space, although dishing, who has recently given the subject much attention, found no such obstruction in the majority of his cases. In these cases the accumulation of fluid may be enormous, distending the cranial cavity to five or six times its natural size (Fig. ISO). The bones are widely separated, the brain is converted into a thin-walled sac, and all surface-markings are obliter- DISEASES OF THE BRAIN 365 ated. The child shows little or no mental activity, and death often occurs at an early period. In less severe cases, when life is prolonged, the child may be an idiot or imbecile. The acquired variety may be due to some new growth pressing on the iter or the veins of Galen, or to meningitis. The external form is not infrequently associated with chronic internal pachymeningitis. Treatment. — The treatment of this condition is unsatisfactory. External pressure is of no avail. Ventricular tapping gives only temporary relief, and permanent external drainage is practically always followed by sepsis. Draining the ventricular cavity into the subdural space would seem to be the rational plan of treatment, and if it could be accomplished at an early period before permanent press- ure-effects are produced it might prove to be of value. Two or three successful cases have been reported. The author lias on three occasions established an opening into the ven- tricular cavity through the tentorial surface of the occipital lobe, and introduced an inverted T-shaped drain of folded rubber tissue, the horizontal arm resting on the tentor- ium and the vertical portion pass- ing through the opening into the ventricle. Access to the part was obtained through an omega-shaped osteoplastic flap, which was after- ward replaced and tightly sutured without drainage. One patient lived six weeks with marked im- provement, the head diminishing some three inches in circumference; the others died as the result of operation. Alfred S. Taylor has recently reported a series of cases resulting from epidemic cerebrospinal meningitis in which he drained the ventricles into the subdural space over the convexity, using sev- eral strands of catgut instead of the rubber tissue. Cushing, in the cases in which a communication can be demon- strated to exist between the ventricles and the subarachnoid space, advises the establishment of a communication between the spinal arachnoid space and the retroperitoneal areolar tissue by means of a trephine opening through the body of the fifth lumbar vertebra and the introduction of a silver canula. Meningocele ; Encephalocele ; Hydro-encephalocele— Meningocele is a protrusion of one or more of the cerebral membranes through a congenital aperture in the skull. This usually occurs in the median line of the occipital or frontal region, the protrusion appearing as a large or small oval cystic tumor beneath the scalp which increases in Fig. 180.— Hydrocephalus. 366 INJURIES AND DISEASES OF HEAD AND BRAIN size and tension on coughing or crying. Fluctuation is generally present and the contents may be diminished by pressure (Fig. 181). Encephalocele is the protrusion of a portion of brain tissue within a meningocele. Hydro-encephalocele is an encephalocele which contains also within the brain substance a cavity communicating with the ventricle. These conditions are all due to congenital defects and in most instances the tumors are present at birth. The larger and perhaps the most frequently observed instances are those belonging to the hydro-encephalocele class. Treatment. — The treatment of these conditions is very unsatisfactory as a rule. Extirpation of the sac, with ligature of the pedicle and closure of the wound, is to be advised in meningocele and encephalocele when the brain substance can be reduced. The insertion of a celluloid plate, between the scalp and the surrounding bone, is to be recom- mended to prevent recurrence. Removal of a protruding portion of the brain substance may be attempted. When no operative measures seem advisable the child should wear some protecting apparatus to avoid rupture from blows or falls. Hernia Cerebri. — Hernia cere- bri is the protrusion of a portion of the brain through an opening in the skull. This condition is frequently observed after com- pound fractures and operations on the brain when marked intra- Fig. 181.— Cerebral meningocele. cranial pressure is present. The protrusion may occur be- neath the healed scar of such an injury, or it may occur before closure of the wound. In the latter case the condition is perhaps more accurately described as prolapse of the brain. The condition is extremely troublesome, as the protruding portion consists of a fungat- ing bleeding mass, which may readily become infected and is a source of great annoyance to the patient. Treatment. — The treatment should consist in an attempt to cover the mass with sound skin, or, better, with a bone flap. To accomplish this, excision of the protruding mass may be necessary. The operation is a difficult one, and is attended with considerable danger. When the skin is unbroken the hernia may be treated by an external protect- ing plate of celluloid or metal, or such a plate may after reduction be inserted between the scalp and the bone. Traumatic or Focal Epilepsy. — When, following a severe trauma of the head, presumably associated with some injury to the brain or its membranes, a previously healthy individual becomes epileptic, the condition is spoken of as a traumatic epilepsy. When, in a given case of epilepsy, the seizure invariably begins in a certain group of muscles DISEASES OF THE BRAIN 367 and always progresses in a regular order which corresponds to the areas in the motor region of the brain cortex which would be affected by an irritation spreading from a given point, the condition is called focal or Jacksonian epilepsy. In these cases the cause of the epileptic attack is probably a local one situated at the point of injury or in that part of the motor area of the cortex which corresponds with the group of muscles first attacked by the seizure. In these cases exploratory operations are indicated, and removable lesions are frequently found which fully account for the symptoms. The lesion may be a depressed spicule of bone, an adhesion between the dura and pia, a dural, pial, or cortical hemor- rhage, or a cyst resulting from such a hemorrhage, a patch of meningeal thickening, a small cprtical abscess or tumor. Treatment. — The treatment of these cases should consist in an exploratory osteoplastic resection of the skull, with relief of pressure from any cause, separation of adhesions, removal of a foreign body or solid tumor, evacuation of a cyst or cortical abscess, or in some instances complete excision of a hopelessly diseased cortical area. Prognosis. — The prognosis should be guarded, for although the original cause of the disease may be removed, the "epileptic habit" is often established, which will require a continuance of the ordinary medical treatment for some time after recovery from the operation. It has been suggested by Jonnesco to remove the two upper cervical ganglia of the sympathetic for cure of the ordinary idiopathic epilepsy. The operation, which is described in Chapter XI, has been followed by improvement in a few cases, but the number of failures is so greatly in excess of the successes that the operation has fallen into dis- favor. Traumatic Cephalalgia. — Severe persistent headache following a cranial trauma and accurately localized on the supposed seat of injury is due, not infrequently, to some local lesion similar to those producing epileptic seizures. The probability of such an association is accen- tuated if pressure over the scar or seat of injury is painful and acts as an exciting cause of the headache. In these cases exploratory opera- tion is to be advised if the symptoms are of such a character as to justify the comparatively slight risk of such a procedure. The Cerebral Injuries of the Newborn. — The terms infantile cere- bral palsy, congenital spastic paralysis, etc., are generally employed to indicate physical defects which are the direct result of injuries to the brain occurring during parturition. Idiocy, imbecility, and epilepsy are also not infrequently due to these injuries. In the great majority of instances the lesions in these cases are due to hemorrhages, lacerations of the meninges or of the cerebral substance, to edema, to an increased intracranial tension, and to the frequently associated asphyxia. The investigations of Gushing, Carmichael, and others have shown that in many, if not the majority of these cases, the primary lesions 368 INJURIES AND DISEASES OF HEM) AND BRAIN are located over the convexity of the cerebrum and near the superior longitudinal sinus. It is obvious that if these cases can be successfully operated upon during the first few days after birth, the clots removed, and pressure relieved, many of the disastrous secondary lesions can be avoided. The subject is a new one, and comparatively little attention has been paid to it by surgeons, but the brilliant success which has been achieved by ( 'ushing in several such instances lead to the belief that much may be accomplished by early operation in these otherwise hopeless cases. In operating upon these cases the same methods should be employed as in adults, great care, however, being necessary in the administration of the anesthetic and in the measures employed to maintain the body temperature and to combat shock. Among the other causes of idiocy and imbecility some authors include premature ossification of the sutures and fontanelles, causing intracranial pressure from a failure of the skull to expand to meet the requirements of the growing brain. In these cases linear craniectomy has been advised. The operation consists in making one or more incisions through the skull parallel with the sagittal suture and extend- ing from the frontal region to the occiput. Supplementary incisions are sometimes made at an oblique or right angle to these, which allow a very considerable amount of expansion of the skull. As there is little or no reason to believe that the mental defects are in any way dependent on the early closure of the sutures, the operation has little to recommend it, and lias been generally abandoned by surgeons. TUMORS OF THE BRAIN. The tumors which occur in the brain or grow from its membranes are, in the order of frequency: syphilitic or tuberculous granulomata, endotheliomata, gliomata, sarcomata, angiomata, psammomata, fibromata, neuromata, and cysts. Symptoms. — These depend entirely upon the situation of the tumor and the structures pressed upon by its growth. It not infrequently happens that tumors even of considerable size may exist for months or years in one of the silent areas of the brain without producing symptoms which lead one even to suspect intracranial disease. On the other hand, comparatively small growths in other regions may produce a train of symptoms of the most painful and distressing char- acter, making life unbearable and driving patients to suicide. The four cardinal symptoms of brain tumor are headache, vomiting, vertigo, and optic neuritis. While all of these symptoms are usually present at some period in the history of most cerebral tumors, they are by no means always early symptoms, and are certainly not pathognomonic of new growths, for they may occur in any intracranial disease which produces ventricular distention or slowly developing pressure from other causes. These four symptoms may be called the general symp- TUMORS OF THE BRAIN 369 toms of tumor, and are usually present whatever its location. In addition to the changes in the disk, Harvey Cushing has recently called attention to another important and very early ocular sign of intracranial pressure, which is frequently the first positive indication of cerebral tumor. This sign consists in the demonstration of a change in the color fields, with irregularity and overlapping of the various color areas. The general blood-pressure is not increased in the majority of the cases. Many other symptoms may be present, due to the location of the growth, and may be spoken of as the special or localizing symptoms, for by their presence or absence conclusions may often be drawn regarding the probable situation of the growth. Of the special symp- toms which may be 'produced by the growth of a cerebral tumor, the most important are those caused by the irritation or paralysis of certain well-known cortical centres or the origins of the cranial nerves. Thus in tumors of the motor area we have Jacksonian epilepsy, mani- fested in the muscles of the face or extremities on the side of the body opposite to the lesion ; or if the pressure is greater, paralysis of one or more groups of these muscles will result. In tumors of the superior parietal convolution, astereognosis is observed. In tumors of the prefrontal region there may be no localizing signs, but mental disturb- ances are of frequent occurrence, especially if the lesion is in the left hemisphere (Phelps). In growths affecting the posterior extremity of the third left frontal convolution motor aphasia is present. In tumors of the occipital lobe and of the posterior portion of the parietal lobe, visual disturbances are common, while in the temporosphenoidal lobe, especially on the left side, a tumor may give rise to deafness and impairment of the senses of taste and smell. Tumors at the base of the brain may produce hemiplegia, hemi- anopsia, hemianesthesia, with paralysis of one or more of the cranial nerves. Tumors of the hypophysis give rise to bitemporal hemian- opsia, severe headache, symptoms of acromegaly, and loss of sexual power. Tumors of the cerebellopontine angle, the so-called acoustic neuromata, cause a distressing tinnitus, unilateral deafness, and later, give rise to paralysis of the fifth, sixth, and seventh nerves. Tumors of the cerebellum, if near the worm, produce marked ataxia and staggering gait; the patients, when asked to walk a straight line, will more frequently stagger away from the side on which the tumor is located, than toward it. Cerebellar tumors also give rise to a rapidly advancing choked disk and nystagmus. Nerve deafness when present may be regarded as a reliable indication of the situation of the tumor. It occurs on the same side as the lesion, while the other cranial nerve palsies occasionally present in cerebellar tumor may occur on either side. Tumors of the medulla are generally rapidly fatal, the early symptoms being cardiac and respiratory disturbances with dysphagia and cranial nerve palsies. Of all the symptoms of cerebral tumor, pain and vomiting are the 24 370 INJURIES AND DISEASES OF HEM) AND BRAIN most distressing. The pain is seldom definitely localized, but it is progressive in character, eventually becoming so severe as entirely in prevent sleep, and, with the uncontrollable vomiting, produces a condition of extreme exhaustion. Occasionally the headache is more localized, but too much reliance should not be placed on this symptom in locating the lesion, for the reason that prefrontal growths often are accompanied by severe occipital pain, and cerebellar tumors not infrequently give rise to pain located chiefly in the frontal region. There is little to help us in determining the nature of the growth. A well-marked history of syphilis, and the fact that the early cerebral symptoms were of a transitory nature, and varied in character, would indicate the probability of a syphilitic gumma; while a tuberculous history and the evidences of tuberculosis in other organs would favor the belief that the growth was of tuberculous nature. The occurrence of cerebral symptoms following malignant disease in other organs would suggest the probability of a meta>tasis of malignant character. Rapid development of symptoms and evidences of pressure would suggest a rapidly growing sarcoma rather than a more slowly develop- ing glioma or fibroneuroma. Psammomata occur chiefly within the ventricles or the region of the lateral recesses and the flocculus. Hydatid cysts of the dura and tentorium have been reported. Cystic formations caused by blood-clots are of fairly frequent occurrence, but as they show no tendency to grow they rarely produce severe symptoms. Prognosis. — The prognosis in non-syphilitic tumors of the brain is grave. Unless relief is afforded by surgical means the termination is invariably fatal. Treatment. — Syphilitic gummata of the brain should be treated by salvarsan, increasing doses of potassium iodide combined with mercury, administered by the mouth, inunction, or hypodermic injection. The iodide should be given in large doses, as improvement frequently does not manifest itself until from 100 to 300 grains are given daily. Tumors of a doubtful nature should also receive the benefit of this treatment for purposes of diagnosis. While the vast majority of tumors of the brain are inaccessible for surgical treatment, in a few instances (about 7 per cent.) tumors are located in region> in which they may be successfully exposed and extirpated. Whenever there is a reasonable probability that a non-syphilitic tumor is located at or near the surface of the cerebrum or cerebellum the region should be exposed by an osteoplastic resection of the skull, the dura opened, and the surface of the brain examined. Absence of pulsation and an induration appreciated by palpation suggest the possibility of a sub- cortical growth. Solid tumors may be recognized by their appearance and density, angiomata by their pulsation and compressibility, cysts by the sense of fluctuation. Gliomata are often difficult of recognition on account of their soft consistence and the fact that when situated OPERATIONS ON THE BRAIN 371 beneath the surface they present an appearance only of an enlarged convolution and have no sharply defined borders. Exploratory puncture of the brain by means of a director or blunt-pointed probe will occasionally reveal the presence of a tumor at some distance from the surface. Incision through the cortex and palpation of the deeper parts with the finger enabled the writer on one occasion to detect a hard cerebellar tumor situated about one inch from the surface. When located, the tumor can generally be removed by enucleation by the finger, a sharp spoon, or a flat periosteum elevator. Hemorrhage should be checked by ligation of the pial vessels and the liberal use of hydrogen peroxide in the cavity, followed by packing with sterile gauze. If no hemorrhage follows removal of the tumor, only a small rubber tissue drain should be left in the wound, the bone flap returned and sutured in place. If the wound is packed, the flap should not be sutured until the packing is removed, or a window should be cut in the bone to allow of its subsequent removal. While these procedures are accompanied by grave dangers, the risk is justifiable, for the disease if left to itself is invariably fatal. When the tumor cannot be accurately located or when its complete extirpation is impossible, removal of a large piece of the skull with an opening in the dura will often relieve the intracranial pressure and bring about a marked amelioration in the pain, vomiting, optic neuritis, and other distressing symptoms. A favorite site for such decompres- sion operations is, as suggested by Gushing, in the temporal region, as the resulting disturbances are less than when more important areas are crowded through the cranial defect. Whenever the opening in the skull is near the motor area, paresis or paralysis is apt to follow the operation from pressure of the cortex on the bony margin of the opening. OPERATIONS ON THE BRAIN. As the special procedures which are indicated in the surgical treat- ment of the different brain-lesions have already been described, it remains only necessary to describe the methods of opening the skull and gaining access to the various regions of the cranial cavity. Trephining. Craniotomy. — While the term "trephining" literally refers to the act of cutting out a circular piece of the skull with a trephine (Fig. 182), it has by common usage been employed to indicate any surgical method of opening the cranial cavity. Before proceeding to open the skull, the patient's head should be shaved and the chief fissures and other landmarks laid out and per- manently marked on the scalp by needle-scratches. After this is done the entire scalp should be carefully prepared for an aseptic operation. After the patient is anesthetized the region to be explored is deter- mined and the centre of the proposed opening indicated by the mark of an awl driven through the soft parts into the bone. If the trephine is to be used, a generous curved incision should be made through 372 INJURIES AND DISEASES OF HEAD AND BRAIN the tissues of the scalp down to the bone, the soft parts retracted, and the awl-mark located. The central pin of the trephine should be placed over this mark and the trephine rotated backward and forward until a distinct groove is cut in the bone. The pin is then drawn upward and the sawing continued until the inner table is perforated at one or more points. This is indicated both by the sensation imparted to the hand and by exploration of the cut with the flat end of a probe or wooden toothpick. The button of bone can be removed by lateral manipulation of the trephine or by a narrow periosteum elevator. After the button of bone is removed, the opening in the skull may be enlarged to any extent by rongeur forceps. Fig. 182.— Trephine. Osteoplastic Craniotomy.— When the osteoplastic method is em- ployed, an omega-shaped incision is made, the base of which will be so situated as to contain the bloodvessels and nerves supplying the part (Fig. 183). This incision is carried to the bone, but without retracting the soft parts any more than is necessary to expose freely the curved line of the bare* bone at the bottom of the incision. The bone is divided by the Gigli saw (Fig. 184) through a series of small trephme- openings; or one of the various forms of the surgical engine may be employed. When the bone is sufficiently loosened, it is carefully raised* by an elevator, the soft parts remaining attached, and is broken off at the base of the omega. As the size of the opening which may be made by this method is unlimited, large areas of cerebral cortex can be examined, and, after the necessary procedures have been carried out, the bone may be replaced, the soft- parts sutured, and no defect OPERATIONS ON THE BRAIN 373 in the skull remains. This method in skilful hands is quicker than that by the use of the trephine; it gives far greater exposure and leaves no weak spot for the subsequent development of a hernia. After the skull has been opened by either of these methods the dura may be divided by a curved incision, which is best made by a fine pair of curved scissors. The further steps of the operation are deter- mined by the character of the lesion, and have already been described. In closing such a wound the dura should be united with catgut, the scalp by silkworm gut, a large dressing of sterile gauze and cotton should be applied and held in place by a starch or dextrin bandage. To expose the cerebellum Cushing employs a T-shaped incision through the soft parts, laying bare both halves of the occipital bone. He then removes enough bone to expose thoroughly both hemispheres. Fig. 183. — Osteoplastic resection of skull, after Wagner. Fig. 184. — Gigli saw. By partly dislocating one lobe, he is able to retract the other sufficiently to gain access to the cerebello-pontine recess without lacerating the cortex or producing dangerous pressure on the medulla. Cushing's temporal decompression operation consists in exposing the bone by means of a curved incision above the zygoma, separating, but not dividing, the fibres of the temporal muscle, and removing a sufficient area of bone and dura to give relief of the intracranial press- ure; after which the soft parts are accurately replaced and sutured. In cases of extreme tension the operation may be performed on both sides. For additional data on the technic of cerebral operations and for a description of the rarer procedures, as the approach to the hypophysis, etc., the reader is referred to the recent monographs of Horsley, Hartley, and Cushing. CHAPTER XVI. INJURIES AND DISEASES OF THE SPINE. ANATOMY OF THE SPINAL CORD. The spinal canal is the space enclosed between the bodies, trans- verse processes and laminae of the vertebrae and the ligaments which bind them together. It is always larger than the spinal cord. It is lined by a layer of fat which is interposed between the bony ligamen- tous canal and the sheath of dura mater. Between the dura mater and the pia mater which is closely applied to the spinal cord there is a considerable space which is filled with cerebrospinal fluid. On either side there extends from the dura mater to the pia mater a series of processes composed of the arachnoid, the ligamenta dentata which supports the spinal cord in the canal. The spinal cord begins above just below the decussation of the pyramids opposite the atlas and extends down to opposite the second lumbar vertebra, where it tapers off into the filum terminale. The spinal nerves have an intraspinal course which increases from above downward. The spinal cord is considered as composed of different segments, one for each pair of spinal nerves. The relationship of these segments to the vertebral spines is shown in Fig. 185. The sen- sory distribution of each segment is shown in Plate XIII. The sen- sory distribution of peripheral nerves is shown in Fig. 1SG. Within the white matter of the spinal cord are arranged the different fibres which convey impulses from the periphery to the central nervous system and from the central nervous system to the periphery. In considering lesions of the cord one should bear in mind that the terms used, although the same as those employed in lesions of the brain do not have the same significance. Compression of the cord, for example, refers to the effect of local pressure, as we cannot distinguish any general pressure. INJURIES AND DISEASES OF THE SPINE AND CORD. Fractures of the Spine. — Fracture of the spine is so often accom- panied by a dislocation that the two forms of injury had best be considered together. Injuries of this kind generally result from a fall or some severe crushing force which violently bends the vertebral column. Parts of one or more of the vertebrae may be fractured by a direct blow, as the spinous process or vertebral arches, and occasionally PLATE XIII Areas of Anesthesia upon the Body after Lesions in the Various Segments of the Spinal Cord. The segments of the eord are numbered: C I to VIII, D I to XII, L I to V, S 1 to 5, and these numbers are placed on the region of the skin supplied by the sensory nerves of the corresponding segment. (Starr.) ANATOMY OF THE SPINE AND CORD 375 .X. to rectus lateralis J2-to rectus antic, miliar . Anastomosis with hypoglossal .Anastomosis with pm umogastric _X. to rectus antic.major. .JIT, tu mastoid region. .Great auricular n. -Transverse cervical n. X. tu Trapezius, Ana. Scap. and Rhomboid. JSupra- < .Phrenic n. N. to levator aug. scap. If. to rhomboid Subscapular n. .Subclavicular n. N. to pectoralis major. .Circumflex n. Musculo-cutaneous n. Median n. Radial n. Ulnar n. Internal cutaneous n. Small internal cutaneous n. Ilio-hypogastric n. llio-inguinal n. .External cutaneous n. .Genito-crural n. Anterior crural a. Obturator n. \ to tphim ter ani Coccygeal n. Superior gluteal n. X. to piriformis X. to gemellus super. X. to gemellus infer. X. to quadrutus Small sciatic n. Sciatic n. Fig. 185. — The relation of the segments of the spinal cord and their nerve roots to the bodies and spines of the vertebrae. (Dejerine et Thomas, Mai. d. 1. Moelle Epiniere, Paris, 1902.) Fig. 186. — The distribution of sensory nerves in the skin. (After Flower.) The areas of the skin supplied by the cutaneous nerves are shown in finely dotted outline. The circles on the trunk show areas occasionally anesthetic in hysteria. The lines across the limbs at ankle, knee and thigh, wrist, elbow and shoulder show the upper limits of anesthesia in multiple neuritis of varying degrees of severity. ANATOMY OF THE SPINE AND CORD 377 muscular action may play a minor part in the injury. Pure disloca- tions are rare, five-sixths of the cases occurring in the cervical region. (Chapter XXX.) Fractures are more commonly met with in the cervi- cal and dorsal regions, the most frequent point of injury being the fifth and sixth cervical, the last dorsal, and first lumbar. The line of fracture, when the body is involved, may be in any direction, but is generally transverse or oblique (Fig. 187). Comminution may occur, and occasionally impaction takes place, giving rise to angular deformity without displacement. In by far the greater number of these injuries there are both fracture and dislocation, a condition which has been termed fracture-dislocation. While fracture of a portion of a vertebra may occur without producing any injury of the cord, in the great majority of cases these injuries result in a temporary or permanent Fig. 187. — Transverse fracture of vertebra. (Stimson.) Fig. 188. — Displacement of the vertebrae causing compression of the spinal cord. displacement which gives rise to a more or less serious cord lesion (Fig. 188). It occasionally happens that the immediate displace- ment which has produced a permanent transverse lesion of the cord has been spontaneously reduced before the patient is seen by the surgeon. The cord lesion may be simply a contusion from the driving inward of a fragment of a fractured arch, compression from displaced bone, or hemorrhage which may be extradural, in the subdural space, or in the anterior horn of the gray matter of the cord (hematomyelia) ; or the cord may be crushed and its functions permanently impaired by the deformity which follows the severe forms of this injury. Symptoms. — The symptoms of fracture of the spine are of two kinds: those due to injury to the spinal column, and those due to injury of the cord. The former are deformity, localized tenderness, 378 INJURIES AND DISEASES OF THE SPINE pain on movement of the trunk, and crepitus; the latter are sensory and motor paralyses, retention of urine, involuntary movements of the bowels, priapism, the formation of bed-sores, variation in the reflexes, and occasionally hyperpyrexia. In fracture without dislocation there may be no deformity present; generally, however, there is a prominence of one or more of the spinous processes, which may amount to a well-recognized angular deformity. In fracture of the spinous process there may be a depression over the injured process. Localized pain and tenderness are practically always present, but crepitus is frequently absent. Fracture or dislocation of the atlas and axis is very rare, and is almost always fatal either immediately or after a few days. The symptoms of fracture or dislocation of the upper four or five cervical vertebra? are more or less complete paralysis of motion and sensation below the injury, rigidity of the neck, localized pain, embarrassment of the respiration, priapism, and hyperpyrexia. There may be no recognizable deformity. Fracture or dislocation of the lower cervical and upper dorsal presents noticeable deformity; the paraplegia is generally complete to the region of the diaphragm, irregular above this point. Paralysis of the upper extremity may develop immediately or after several hours or days. There is absence of thoracic respiration, and paralytic myosis may be present. It is generally rapidly fatal if the phrenics are involved; more slowly if below that point. Fracture-dislocations of the dorsal and lumbar region are less rapidly fatal, and when below the eleventh dorsal the paralysis may be incom- plete owing to the rarity of marked displacement in this region, and consequently less complete injury to the cord, and also to the fact that below the second lumbar vertebra the canal contains only the cauda equina, a bundle of nerve trunks. Partial or complete recovery from the paralysis may take place after these fractures. Not infrequently after injuries to the spinal column there is complete paraplegia, with paralysis of the bladder and rectum and the rapid formation of bed-sores, thermo-anesthesia, but without loss of tactile sensation. In these cases the lesion is not a crushing injury of the cord, but a hemorrhage into the anterior horns of the gray matter (hemato- myelia). If no other lesion exists, recovery from this condition may be confidently expected in from six to twelve weeks. Treatment. — In the treatment of fracture or dislocation of the spine the surgeon should be guided by the probable condition of the cord. In all cases in which there is reason to believe that the injury to the cord is not a crushing one, attempts should be made to reduce the displacement if any exists, and to bring about a union of the fracture by fixation. This is sometimes effected in the cervical region by extension and counter-extension, aided by manipulation at the seat of injury, and should be followed, if successful, by the application of a plaster collar and head bandage. In fractures of the dorsal and lumbar ANATOMY OF THE SPINE AND CORD 379 regions reduction is often aided by suspension. In the majority of instances, however, reduction of a fracture-dislocation can only be accomplished by open operation. In all cases, whether reduction is accomplished or not, fixation by a plaster jacket gives comfort to the patient and favors union. The question of operative intervention in injuries of this kind is one upon which there is considerable difference of opinion. In crushing injuries of the cord restoration of function never occurs, so that relief of pressure by operation could be of no possible value. On the other hand, hematomyelia, in which the prognosis is favorable, Fig. 189. — Intradural hemorrhage due to fracture-dislocation which had been spontaneously reduced. recovers as well without as with operation. This leaves only the cases in which the symptoms are due to pressure from depressed bone or hemorrhage, upon which operation offers any chance for improvement. In these cases laminectomy may reveal the cause of the pressure, which can sometimes be removed. It should be remembered, however, that hemorrhage may exist with a crushing injury of the cord, which upon inspection through an opening in the dura shows no macroscopic sign of injury. Fig. 189 represents such a condition, in which the writer believed that complete recovery would probably follow removal 380 INJURIES AND DISEASES OF THE SPINE of the clot, whereas upon microscopic examination the cord was found to be wholly disintegrated by a crushing injury. In an organ as deeply seated and as well protected as the spinal cord it is difficult to understand how it can be structurally injured by a blow or other trauma applied to the back which does not produce a fracture or dislocation of the bony canal. That such is the case, however, is evidenced by an abundance of pathologic material. Concussion, Contusion, and Multiple Punctate Hemorrhage of the Cord. — Much controversy has arisen regarding these three con- ditions, the existence of which as distinct pathologic processes, unasso- ciated with other graver lesions, and recognizable during life, is open to question. While we are not prepared to deny that distinctly spinal symptoms, as pain, numbness, more or less complete paralysis of sensation and motion, relaxation of the sphincters, etc., may be present for a short period following spinal traumata, which do not exhibit evidences of grave and more permanent lesions, and may perhaps be conveniently classed under the term concussion of the spine, that such symptoms may persist for any considerable period of time has not been proved. These cases should be clearly differentiated from those of traumatic neurasthenia and hysteria, in which the only spinal symptoms present are purely subjective in character, and the chief disturbances are mental and emotional rather than physical. Spinal Hemorrhage. — By spinal hemorrhage is meant a hemorrhage of sufficient extent to produce pressure-syinptoms, which may occur as a result of trauma, within the bony canal of the spine. Extradural and Subdural Hemorrhages. — Extradural and Subdural hemorrhages are described in most works on surgery. They are present in practically all cases of severe injury to the spine, and by their presence and the pressure they exert may modify to a certain extent the symptoms present in such cases. If they ever occur unassociated with fracture or dislocation or without injury to the cord, they are surgically unimportant, for they cannot be recognized during life (Bailey). Hematomyelia ; Intramedullary Hemorrhage. — This condition, as accurately described by Bailey, is of fairly frequent occurrence. It is chiefly confined to the cervical region, and is generally caused by sudden forcible flexion or extension of the vertebral column, without fracture, such as results from diving in shallow water and striking the head violently against the bottom. The hemorrhage occurs chiefly in the anterior horn of the gray matter, and may extend upward or downward for a considerable distance. Occasionally it spreads to both sides of the cord and involves the posterior horns. Symptoms. — The symptoms are often complete muscular paralysis below the lesion with varying sensory disturbances, of which loss of sensibility to heat and cold, and to pain, with normal tactile sensibility, are the most characteristic. Paralysis of the bladder and rectum may be present and bed-sores occasionally develop. AX ATOMY OF THE SPIXE AND CORD :;m Prognosis. — The prognosis depends upon the extent of the hemor- rhage. In general it may be said that in an ordinary ease of hemato- myelia partial or complete recovery may be expected within two or three months. Treatment. — The treatment of spinal hemorrhage consists in rest and careful nursing, to avoid bed-sores and cystitis. Transverse, Crushing Lesions of the Cord from Fracture, Dislocation, or Direct Wound. — This is the pathologic condition commonly present in cases of "broken back." The injury is caused in these cases by the crushing force of a displaced vertebral segment, which, however, frequently springs back into place before the patient is seen by the surgeon, leaving no obvious sign of dislocation or fracture with displacement. Symptoms. — The symptoms of a complete transverse lesion of the cord are total paralysis of sensation which is symmetrical on the two Fig. 190. — Thorburn's position in fracture of spine. sides of the body and motion below the point of injury with immediate absence or diminution of reflexes (these, however, may return at a later period or become exaggerated). The muscles supplied by the injured segment atrophy and present the reaction of degeneration. The muscles supplied by the segments below the injury subsequently contract, become rigid and show normal electrical reactions. Trans- verse lesions of the cord at or above the fourth cervical segment are rapidly fatal from paralysis of the muscles of respiration. If the lesion lies below the origin of the phrenic nerves life may be somewhat prolonged. In fractures in the neighborhood of the fifth and sixth segments Th orb urn describes a characteristic attitude: The patient lies with the arms abducted and rotated outward, the elbows flexed, and the forearm supinated. There is total paralysis of sensation and motion below the point of injury, with priapism, paralysis of the rectum and bladder, and the formation of bed-sores. Respiration 382 INJURIES AND DISEASES OF THE SPINE is embarrassed and asphyxia may occur from inability of the patient to expel mucus from the trachea and bronchi. In lesions of the lower dorsal and lumbar regions the prognosis as to life is better, death generally taking place from sepsis due to bed-sores or infection of the bladder and kidneys. The evidence is very slight that in a total transverse lesion the cord is ever regenerated to a sufficient extent to result in a restoration of function. Treatment. — The treatment in cases of total transverse lesions of the cord should consist in careful nursing to avoid bed-sores and infection of the bladder. Pressure over the sacral region should be avoided by rubber rings, and the parts should be kept scrupulously clean. The position of the patient should be frequently changed, and all pressure-points frequently bathed with alcohol. Regular aseptic catheterization is necessary. The application of a plaster jacket is advisable to keep the parts at rest. Incomplete Crushing Lesions of the Cord. — These may occur in fractures of the vertebral arches and in partial luxations. The symp- toms are incomplete paralysis of sensation and motion, the distribution of the anesthesia being asymmetric. In place of complete loss of subjective symptoms there is pain of a sharp lancinating character, and other sensations as formications and tingling. The reflexes are not completely lost. In these cases, which are rare, exploratory operations are indicated for the detection and removal of depressed fragments of bone and to relieve pressure on the cord. Injuries to the Cauda Equina. — Below the first lumbar vertebra fractures of the spine injure only the cauda equina, and while sensory and motor paralysis, absence of reflexes and trophic disturbances follow these injuries and closely simulate injuries of the cord, several points of difference may be enumerated. Cord injuries, as a rule, are not associated with pain. Injuries of the cauda give rise often to severe pain, especially in the hyper- esthetic zone just above the paralyzed area. In injuries of the cauda the anesthesia is irregular in distribution and generally less in extent than in cord lesions. The cauda, being made up of peripheral nerves, is capable of repair after injury, and for that reason recovery more frequently occurs than after crushing injuries of the cord. The tissues of the cauda are more resistant to injury than the cord ; a given trauma will therefore produce more complete destruction of the latter than of the former structure. In spinal injuries above the second lumbar vertebra both cord and cauda may be injured, evidenced by the occurrence of sensory disturb- ances one or two segments above the level of the cord injury. In these cases evidence of severe injury to the nerve roots renders the prognosis more grave, as it is probable that the injuring force was sufficiently severe to produce a crushing lesion of the cord. SPINAL TUMORS 383 OPERATIVE TREATMENT OF SPINAL INJURIES. As sufficient regeneration to insure a return of function never occurs after complete transverse crushing lesions of the cord, operation is of no value. As the symptoms of hematomyelia frequently disappear spontane- ously, and as the lesion cannot be influenced by operative interven- tion, operation is distinctly contra-indicated. This leaves only the incomplete injuries of the cord and the lesions of the cauda equina, which are likely to be benefited by operation. If, therefore, an accurate diagnosis could be arrived at in all cases at the time of injury, the operative indications would be clear. Unfor- tunately, however, this is not the case, as Mixter, Munro, and others have reported cases recovering after operation when the symptoms clearly pointed to a crushing lesion of the cord. Most surgeons now agree with Walton, McCosh, and Keen, who advocate an exploratory laminectomy after a reasonable period of observation in all cases of doubt regarding the character and extent of a given cord injury. SPINAL TUMORS. Tumors causing pressure on the spinal cord may grow from the bony spine, from the spinal membranes, or from the cord itself. Tumors of the bone are generally malignant in character and are most frequently secondary to deposits elsewhere. Exostoses and chondromata have been reported. Of the meningeal tumors which form the most important class, sarcomata and endotheliomata are the most common, while myxomata, fibromata, lipomata, and psammomata are occasionally encountered. Sarcomata and gliomata occur in the cord, but are, as a rule, inoperable. Of the infective granulomata, tuberculous and syphilitic are of frequent occurrence, especially the former. These may produce the same symptoms as the genuine new growths. The majority of meningeal tumors develop on the posterior or lateral aspect of the cord, which accounts for the early occurrence of sensory disturbances. Symptoms. — These, as a rule, are classified as root symptoms and pressure signs. Irritation the of sensory nerve roots by a growing tumor gives rise to neuralgic pains, increased by motion; various paresthesias, and later anesthesia. These may persist for months or years before motor symptoms occur. At a later period there occur muscular spasms, paresis, and finally paralysis, with the reaction of degeneration and atrophy. As a rule, the pain diminishes with the advent of the motor paralysis, and in the later stages may be absent. The reflexes at first are exagger- ated, later diminished, and finally lost. Trophic disturbances occur, and the patient finally becomes bed-ridden and helpless. 384 INJURIES AND DISEASES OF THE SPINE In the early stages the symptoms may be unilateral; later, as the cord is more completely compressed, a total paraplegia develops. Regarding the situation of the lesion in the spinal canal, the most reliable data can be obtained from the early symptoms of sensory root irritation. These, with the later distribution of the cutaneous anesthesia and the upper limit of the motor paralysis, will generally enable one to determine the segment of cord involved. 1 Prognosis. — Unlike the behavior of sarcomata in other parts of the body, meningeal sarcomata grow slowly, do not infiltrate the surround- ing tissues, and rarely recur, if removed at a comparatively early stage. For this reason the prognosis in meningeal tumors is favorable if the diagnosis can be made and the growth removed before the cord has been compressed to such a degree as to destroy the conductivity of its fibres. Infiltrating tumors of the cord are obviously beyond the possibility of surgical relief. Fig. 191. — Spina bifida with myelomeningocele. Spinal tumors unless relieved by surgical measures, in the great majority of instances, end fatally. Treatment. — The treatment in all but the secondary or late malignant cases should be early exploratory laminectomy and removal, when this is possible. As Elsberg has pointed out, this may be done in two stages. In the first step the tumor is exposed and possibly the mem- branes over it are incised; it is then allowed to rest for several days, during which time the tumor is extruded and may be readily removed with little or no injury to the cord. Spina Bifida. — Spina bifida is a congenital defect in the spinal column caused by a non-union of the laminse of one or more vertebral segments, usually in the lumbar or sacral regions. Several varieties exist : 1 For a more detailed description of the facts in spinal localization, the reader is referred to the tables and plates in Starr's Organic Nervous Diseases. SPINAL TUMORS 385 Spina bifida occulta, in which the spinal defect exists alone. The region of the defect is apt to be covered with hair. It is often associated with perforating ulcer of the foot. Meningocele. — A hernia of the spinal membrane forming a cystic protrusion covered with epidermis. Meningomyelocele. — A meningocele having the flattened spinal cord on its posterior wall, the commonest variety. Syringomyelocele. — The meninges are defective; the protruding cyst is composed of the tissues of the cord dilated by a collection of fluid in the closed central canal. Very rare. Myelocele. — An imperfect union of the medullary folds. The central canal is open and the medullary folds are spread out on either side and are continuous with the skin. The medullary portion is of a bright red color and highly vascular. Children with myelocele die a few days after birth from constant leakage of the cerebrospinal fluid . Moore, who collected statistics from the literature of the operative cases prior to 1905, states that 23 per cent, occurred in the sacral region, 34 per cent, in the lumbar, 29 per cent, at the lumbosacral junction, and 14 per cent, in the cervical and dorsal regions. The condition is often associated with other congenital defects, as club-foot and hydrocephalus; and in a fair proportion of the cases more or less paralysis of the sphincters and lower extremities is present. Prognosis. — The prognosis of this condition, if left to itself, is grave, the severer types dying shortly after birth, and many of the cases of meningocele and meningomyelocele dying from rupture of the sac and the subsequent development of meningitis. Treatment. — Spina bifida occulta, if well covered by healthy skin, needs no treatment. Small meningoceles without symptoms may be treated by a protective dressing to guard against rupture. The presence of hydrocephalus, extensive paralysis, or other marked deformities would be a contra-indication to operative treatment. Meningoceles and meningomyeloceles without paralysis should be treated by operation. The sac should be exposed by an elliptical incision and freely opened. Any nerve-fibres which do not end in the sac should be dissected out and returned to the spinal canal. The redundant sac should then be excised to a point near the neck, and the dura firmly closed by ligating the neck or by two or more rows of catgut sutures. Lovett then recommends the formation of two rectangular flaps of muscle and fascia with their bases toward the median line. These are inverted and firmly united over the stump of the miningocele by chromic gut sutures, after which the skin is united with silk or silkworm gut. The operative mortality is about 33 per cent., and the secondary mortality, after one or more years, about 30 per cent. Permanent recovery may be expected in about one-third of the casts. 25 :N', ix. JURIES AXD DISEASES OF THE SPJXE OPERATIONS ON THE SPINE. Lumbar Puncture. — Lumbar puncture is practised for the relief of intracranial pressure or for purposes of diagnosis. When practised for relief of intracranial pressure it must be carefully employed in brain tumors because of the danger, especially in the case of tumors of the posterior fossa, that on the relief of pressure the medulla is crowded against the foramen magnum causing instant death. Locate the spinous process of the fourth lumbar vertebra, and after thorough aseptic preparation of the part, introduce an aspirating-needle at a point a half-inch to the left of the spine and carry it obliquely upward and inward between the laminae until the dura is punctured. This will be indicated by a flow of cerebrospinal fluid through the trocar. After sufficient fluid is withdrawn, remove the needle and close the wound with collodion or sterile zinc oxide plaster. Laminectomy. — Laminectomy, or opening the spinal canal, is per- formed for exploratory purposes in fractures, dislocations, and other injuries, and for the removal of tumors. Place the patient face downward on the operating-table, and after thorough preparation of the operative field make an eight-inch vertical incision in the median line over the spine. Divide the soft parts down to the laminae on either side of the spinous processes and retract the edges of the incision. Control the hemorrhage by gauze pressure Next remove the spines by heavy bone-forceps, and with small curved bone-forceps divide the laminae on either side as near the transverse processes as possible, and remove the intervening part of the arch. Several laminae should, if necessary, be removed to give a satisfactory exposure of the cord. If it is necessary to open the dura, it should be incised in the median line and subsequently closed with a continuous catgut suture. Closure of a laminectomy wound should be effected with deeply placed silkworm-gut sutures, a rubber tissue drain being left in the inferior angle of the wound. After an aseptic dressing is placed over the wound a plaster-of-Paris corset should be applied and the patient placed on his back in bed. CHAPTER XVII. INJURIES AND DISEASES OF THE FACE AND NECK, ORAL, NASAL, AND PHARYNGEAL CAVITIES. INJURIES OF THE FACE AND NECK. Contusions. — Contusions of the face are of frequent occurrence, and often produce great disfigurement from the ecchymosis and edema, of which the ordinary "black eye" is the type. Cold applications are usually all that is necessary in the way of treatment. Contusions of the neck occasionally result in serious injury of the nerve trunks, especially the brachial plexus, giving rise to a more or less complete paralysis of the upper extremity. Blows on the neck and angle of the jaw give rise to a severe degree of shock and sometimes to intracranial hemorrhage. Wounds of the Face and Neck. — In wounds of the face great care should be taken to avoid subsequent deformity. Marginal necrosis should be prevented by avoiding too much tension of the sutures. If the edges of the wound are widely separated, one or two retention sutures should be passed at some distance from the edges of the cut, and the margins in this way brought together. The skin should be carefully approximated and united by a number of fine silk sutures, which should be removed as early as possible to prevent scarring. If in wounds of the face, branches of the seventh nerve are divided, the ends should be united with fine catgut. If Stenson's duct is cut, the ends should be accurately united with fine catgut, or the proximal extremity should be drawn outward, passed through an incision in the mucous membrane of the cheek, secured by fine silk sutures, and the external wound closed. In case a fistula results, this may often be cured by wearing a soft probe in the duct introduced through the oral orifice and carried beyond the fistula to the gland, the outer portion of the probe to be curved about the angle of the mouth and secured to the cheek by adhesive plaster. In old cases in which the distal portion of the duct is obliterated a new one may be made by piercing the cheek with a trocar from the fistulous opening inward and forward to a point near the original termination of the duct. This may be kept open by a seton or the probe introduced as above. Freshening and union of the cutaneous wound by sutures or contractile collodion, while the probe is in place, will be required. Superficial wounds of the neck differ in no way from cutaneous wounds elsewhere. They should be throughly disinfected and sutured. 388 INJURIES AND DISEASES OF FACE AND NECK In more extensive wounds penetrating the deep fascia, important structures may be wounded, requiring special treatment. In wounds of the larger vessels the hemorrhage may he temporarily controlled by pressure, but an immediate operation should be undertaken to expose the vessels thoroughly, which should be securely ligated above and below the point of injury, after which the wound should be carefully disinfected and closed with sutures. Wounds of the pharynx, larynx, or trachea, often seen after attempts at suicide by "cutting the throat," are dangerous not so much on account of the immediate injury as by their remote results. Thus in transverse wounds above the hyoid bone the severed tongue or epiglottis may drop backward into the rima glottidis and cause suffocation; in wounds below the hyoid or those severing the thyroid cartilages an edema of the glottis may suddenly appear and cause death from suffocation before help can arrive; while in wounds of the trachea the blood issuing from the neighboring veins or injured thyroid gland may be aspirated and asphyxiate the patient. In all of these cases death from pneumonia may occur at a later period from the inhalation of septic material. The treatment of these cases should consist in arresting all hemorrhage, carefully uniting the divided structures, and performing a tracheotomy below the injured area. In wounds invok- ing the esophagus the walls of this passage should be closed tightly with two layers of suture and the superficial parts brought together with provision for adequate drainage. Wounds of the anterior portion of the neck rarely cause injury to the large nerve trunks (pneumogastric, sympathetic, glossopharyngeal, and phrenic), on account of the deep and protected situation of these structures. Wounds in the lateral portions of the neck, however, frequently cause injury to one or more branches of the brachial plexus. Whenever a nerve trunk is known to have been divided, the ends should be secured and united by suture. INFLAMMATORY DISEASES OF THE FACE AND NECK. Facial Erysipelas. — An acute, rapidly spreading inflammation of the skin and subcutaneous tissue, caused by infection with Strepto- coccus erysipelatis, and accompanied by high fever, rapid pulse, and other evidences of septic intoxication. The local appearances are diffuse redness and edema of the skin, with sharply defined and slightly raised borders. Infection always takes place through some wound or break in the skin, although the point of infection may be so minute as to escape detection. From this point it spreads rapidly, and may eventually cover the entire body. When the disease involves the subcutaneous cellular tissue the symptoms are more severe, a boggy induration occurs, followed by extensive suppuration and often by fatal sepsis. INFLAMMATORY DISEASES OF THE FACE AND NECK 389 Erysipelas of the face generally begins on the bridge of the nose and extends on cither side to the cheeks. When limited to these regions it may present only a butterfly-shaped area of redness without fever or general symptoms of any kind. In other cases more or less well-marked constitutional symptoms may be present, as fever, chilly sensations, anorexia, headache, vomiting, and general prostra- tion. If, however, the disease spreads to the eyelids and scalp, edema occurs, closing the eyes and causing considerable disfigurement. In erysipelas of the scalp the redness is not so marked, but the constitu- tional symptoms are more severe. Occasionally the infection is carried by the emissary veins to the intracranial structures, producing a rapidly fatal meningitis. Erysipelas of the ncch\ if confined to the skin, presents no special features worthy of mention. Treatment. — The treatment of the superficial forms of erysipelas is rather unsatisfactory, as no method can be relied upon to stop the spread of the disease or diminish the toxemia. Small patches occurring on the face may sometimes be aborted by painting with contractile collodion, or the application of lead-and-opium wash. In other locations the use of a wet dressing of carbolic acid ( 1 to 200), aluminium acetate, lead-and-opium wash, or an ointment of ichthyol (10 to 50 per cent.), will be found serviceable. Cellulitis. — In the neck the superficial variety differs in no respect from cellulitis elsewhere, the diagnosis and treatment of which have been considered in Chapter IX. Deep Cellulitis of the Neck (Holzphlegmon.) — When the cellular tissue beneath the deep cervical fascia is invaded, which usually results from a suppurating lymph node, the disease is more serious. There will be at first pain and stiffness of the neck, with edema and a feeling of deep-seated induration and bogginess. The entire lateral region of the neck will appear swollen, but redness of the skin is rare. Chills, fever, sweats, and prostration occur early. The pus may burrow along the cellular planes and eventually reach the mediastinum. Septic thrombosis of the veins may occur and eventually lead to pyemia and death from exhaustion. Treatment. — The treatment of cellulitis should consist in early incision and drainage. The incisions should be free and sufficiently numerous to insure adequate drainage for every pocket of pus. In deep cervical cellulitis the incisions should be made over or just behind the sternomastoid muscle down to the deep fascia. A grooved director should then be thrust through the muscle or fascia. When pus is reached, the opening should be enlarged by a sinus-dilator or pair of dressing-forceps introduced closed and withdrawn open. The cavity should then be explored by the finger or some blunt instru- ment, and another incision made over the most dependent portion of the abscess. Rubber drainage-tubes should be introduced and a wet dressing applied. If the pus has burrowed into the mediastinum, 390 INJURIES AND DISEASES OF FACE AND NECK drainage should be favored by raising the foot of the bed and lowering the head, or it may be necessary to trephine the sternum. Angina Ludovici. — Angina Ludovici is a violent cellulitis marked by an intense hard, brawny swelling with widespread edema, showing little or only a late tendency to break down and form pus, situated in the submaxillary triangle extending backward behind the posterior border of the mylohyoid muscle to the aryteno-epiglottidean folds and larynx and forward along the upper surface of mylohyoid muscle, beneath the mucous membrane on the side of the tongue and the floor of the mouth. This cellular tissue surrounds the submaxillary gland and is inclosed within a fascial and muscular recess which occupies the greater part of the digastric triangle. In this areolar tissue there are imbedded a number of lymph nodes, some of which lie in contact with the capsule of the gland. The disease generally arises by a lymphatic infection from a carious tooth or some other septic focus in the mouth, or rarely from a septic inflammation of the submaxillary gland. The disease is always serious. In virulent cases the inflammation develops with great rapidity, causing gangrene of the areolar tissue and neighboring structures, with a rapidly developing sepsis which may cause death in from five to ten days. Symptoms. — The symptoms are, at first, often those of an acute infectious disease: chills, fever, thirst, anorexia, and a rapid, full pulse. Pain is not always an early symptom, but occurs later, and is often severe and throbbing in character. A painful swelling appears under the jaw, sharply limited by the attachments of the fascia. The tongue is raised and the floor of the mouth is pushed upward. There often result edema and swelling of the aryteno-epiglottidean folds and a resulting inspiratory dyspnea. The temperature is usually not greatly elevated but the pulse is apt to be rapid. There is generally a high leukocytosis. Sudden death from suffocation is frequently caused by edema of the glottis. Treatment. — Treatment should be undertaken at the earliest possible moment, and should consist in free incisions, so placed as to relieve tension on the structures involved; complete removal of the sub- maxillary gland and gangrenous debris will be indicated in all but the earliest cases. The mylohyoid muscle should be divided and the space beneath the floor of mouth drained. The tissue extending backward toward the larynx should be freely exposed with thorough disinfection of the cavity, and packing with sterile gauze. Inflammation and Abscess of the Parotid Gland. — Inflammation and abscess of the parotid gland may occur from pressure in drawing the jaw forward during anesthesia, from wounds, from an ascending inflammation of the duct, or from infection of one of the lymph nodes imbedded in its substance. It is more frequently, however, the result of some general septic disease, as typhoid fever, scarlet fever, or pyemia. The disease generally begins as a circumscribed or diffuse indurated swelling of the gland, with pain, fever, and general malaise. The INFLAMMATORY DISEASES OF THE FACE AND NECK 391 pain is increased by taking food, and stiffness of the temporomaxillary articulation may be present. After several days the mass softens and fluctuation appears. Treatment. — The treatment is by incision and drainage. Care should be taken in making the incision to avoid wounding the external carotid artery or the branches of the facial nerve. Carbuncle. — This disease, the nature of which has been described on page 19 gives a shorter and wider lip and would be recommended when there is an unusual deficiency of tissue. Figs. 214 and 215. — Operation fur complete hare-lip. The intermaxillary hone (Figs. 21s and 219) is not to he removed because of the resulting hideous profile. In the first weeks of life it Figs. 216 and 217. — Brown's operation for bilateral hare-lip. can he depressed somewhat with adhesive plaster and chiloplasty will complete the reduction as shown in Figs. 206 and 207, both drawn to the same scale from casts. Figs. 218 and 219. — Deformities resulting from the protrusion of and absence of the intermaxillary bone. (From photographs.) Uranoplasty and Staphylorrhaphy. — When the operation in an infant occupies two to three hours a fatal termination may be confidently expected. In a simple case and with the facilities for nasal or pharyn- 420 INJURIES AND DISEASES OF FACE AND NECK geal anesthesia at hand, the operation should not exceed an hour. Most operators wait until the child is between two and three years old, but should not defer much longer because it is important to begin speech training early. Avoid sacrificing tissue, impairment of blood supply, and relieve tension. Fig. 220. — Brophy's operation. Brophy operates on the palate in the first weeks of life and seeks to narrow the cleft by forcing the maxilla? together with the aid of wire sutures passed through the entire thickness of the jaws. The sutures are passed through lead plates at either side and are then twisted £t^> Fig. 221. — Lane's operation showing incisions. FlG. 222. — Same with flaps sutured. together as shown in (Fig. 220) to make pressure. The lip is closed at a later date. This method dot's not grow in favor. In the newborn, to avoid perforating tooth follicles, the sutures must be on the level of the floor of the orbit; the nares are so compressed as to preclude HARE-LI V AM) (LEFT PALATE 421 nasal breathing and the dental arch in later life is the despair of an orthodontist. By Lane's method Figs. 221 and -'-1) a very wide defect can be closed. He makes a mucoperiosteal Hap from one side and slides it under a Hap on the other side of the cleft; these are spoken of a> the hinge and pocket flaps. Before the teeth are erupted the hinge flap may be made very wide, extending laterally over the alveolus as it does in Fig. 22 1 in the part of the flap behind the last tooth. Good articulation requires good muscular control of the soft palate and in this operation there is so much dissection of the parts and cicatrization afterward that speech may he little improved. Langenbeck's Operation.-- This is the operation (Fig. 223) usually employed and the one least damaging to the parts concerned. 1. The inner margins of the cleft in the hard and soft palate are denuded so as to give a good raw surface for suturing. Fig. 223. — Langenbeck's operation. 2. With an elevator a mucoperiosteal flap is raised from the whole surface of the bony palate, care being taken to have the uninjured palatine arteries included in the flaps. 3. The soft palate is separated from the posterior margin of the hard palate. 4. If the palate is of the Gothic arch variety it may now be sutured. Usually, however, this would be impossible without too great tension, so incisions are made parallel to the edges of the cleft just internal to the alveolar margin through the mucoperiosteal flaps. 5. The edges of the cleft are sutured with silk, silkworm gut, or linen. At times silver-wire sutures are passed through lead plates to equalize the tension over a larger area of the flap and take some tension from the suture line. 6. Additional tension relieving incisions may be made in the soft palate as indicated by the two short lines in Fig. 223. 422 INJURIES AND DISEASES OF FACE AND NECK DISEASES OF THE NOSE, NASOPHARYNX, AND ACCESSORY SINUSES. Saddle-nose. — Depression or flattening of the bridge of the nose may occur as a result of trauma, septal abscess, syphilis, or tuberculosis. Of these, trauma and syphilis furnish the largest number of cases. In the former, the injury is always direct and results in a more or less comminuted fracture of the structures of the bony framework, particu- larly the nasal bones and septum. Fig. 224. — Syphilitic deformity of the nose. In both congenital and acquired syphilis, gumma of the septum, with later ulceration and necrosis of the bone and cartilages, results in a falling in of the bridge and a characteristic turning upward of the tip. In the treatment of this condition, vigorous antisyphilitic measures should be employed in the specific cases, as long as any inflammatory signs are present. A number of methods of overcoming the deformity have been suggested. Weir advises the use of a celluloid plate. His method consists in making an incision along the nasofacial sulcus, freely separating the skin from the remaining portions of the bone and cartilage, and introducing a sterile plate of celluloid so fashioned as to restore the proper shape to the organ. Care should be taken to avoid wounding the mucous membrane of the nasal cavity. When the celluloid plate is in place the cutaneous wound is closed, without DISEASES OF THE NOSE AND NASOPHARYNX 123 drainage, with fine silk sutures. Recently saddle-nose and other facial deformities due to loss of tissue have been successfully treated by the subcutaneous injection of sterile melted paraffin, which elevates thejdepressed scar-tissue and is easily molded into shape before it hardens. Paraffin melts at 115° F., and should be introduced by means of a well-heated metal aspirating syringe, with a large needle. Fig. 225. — Bone transplantation for nasal deformity. The central figure showy method of elevating skin and subcutaneous tissues; the insert figure shows the bone in place. (Carter.) The needle should be introduced preferably at a short distance from the point where the paraffin is to be deposited and the injection made from above downward with the paraffin in a semisolid state. The reason for this is, that in not less than three instances where these directions have not been carried out the operation has been followed by embolism of the central artery of the retina. 424 INJURIES AND DISEASES OF FACE AND NECK Carter makes an incision at the root of the nose — separates the skin and subcutaneous tissues from the deeper structures, and intro- duces an autogenous bone graft taken from a rib. The inferior extrem- ity of this bone graft is pushed downward to a point near the tip of the nose, and its upper extremity firmly anchored to the frontal bone, by placing it in a small pocket made by raising the frontal periostium. The cutaneous wound is carefully sutured without drainage. (Fig. 225). Partial or Complete Destruction of the Nose. — Partial or complete destruction of the nose may result from malignant disease, syphilis, lupus, or trauma. It is sometimes remedied by rhinoplasty, which consists in grafting skin from some other portion of the body into the defective area. The two methods usually employed are by a flap from the forehead and by a flap from the forearm. In the former method the diseased tissues of the nose are removed, making a triangu- Fig. 226. — Rhinoplasty. Indian method modified. (Stimson.) lar wound, and an oval flap cut from the forehead, curved downward, and stitched in place as seen in Fig. 226. The colunma is fashioned from the lower extremity of the flap and the nasal orifices kept patent by the insertion of two rubber tubes. In the arm method an oval flap is partly cut from the forearm, leaving a deep pedicle attached below. The arm is then carried upward to the face and the cut edge of the flap stitched to the upper margin and one side of the nasal wound. The arm is held in this position for a week or ten days by means of a plaster-of-Paris dressing. When union has taken place, the flap is completely severed from the arm, cut to fit the nasal opening, and stitched in place. To overcome the subsequent depression of the soft transplant Finney, of Baltimore, has advised and successfully prac- tised grafting a finger of the left hand in the nasal defect. Morestin uses an autogenous bone graft in the following manner: A thin section of a rib is transplanted to the forehead between the skin and occipitofrontalis muscle and the wound of entrance sutured. Later DISEASES OF THE NOSE AND NASOPHARYNX 42.") when all signs of reaction have subsided, he employs the first operation described above and illustrated in Fig. 226, cutting the forehead flap in such a manner as to include in its central portion the transplanted bone. Foreign Bodies in the Nose. — Buttons and other foreign bodies are frequently introduced into the nose by young; children. They give rise to pain and a purulent rhinitis. The child should be etherized, cocaine or adrenalin applied to the mucous membrane, and the interior of the nares thoroughly examined by means of a nasal speculum and head-mirror. The foreign body can usually be found and removed by forceps. Epistaxis. — Epistaxis, or bleeding from the nose, may occur from a blow upon the nose or other trauma, from acute congestion, from violently blowing the nose, from sneezing, or from an ulcer of the septum or of the mucous membrane covering the turbinated bodies. Fig. 227. — Plugging the nostrils with Bellooq's sound. (Fergusson.) Treatment. — The treatment should consists in rest, cold applications, or the use of astringent sprays, as cocaine, adrenalin, antipyrin, or tannin. Park recommends equal parts of a 10 per cent, solution of antipyrin and a 10 per cent, solution of tannic acid. If the bleeding point is situated anteriorly, plugging the anterior nares with cotton or gauze will generally arrest the hemorrhage. If this fails, plugging the posterior and anterior nares will give prompt relief. To accom- plish this, a soft-rubber catheter having a loop of silk or linen thread tied about its free extremity, or a Bellocq canula (Fig. 227), armed with a similar loop, is passed through the nose into the pharynx. Through this loop is passed a loop of heavy twine, to which is attached a fine-meshed folded sponge or gauze pad. The loop is drawn outward through the nose and the sponge drawn snugly into the posterior 426 INJURIES AND DISEASES OF FACE AND NECK nasal orifice. When this is secured, a second plug should be inserted into the anterior orifice and retained by tying the two arms of the projecting loop. This should be allowed to remain in place for from thirty-six to forty-eight hours, after which it can be removed by a third strand of twine which passes from the sponge outward through the mouth . Inflammation of the Maxillary Antrum. — Inflammation of the max- illary antrum is usually a sequel of an acute septic rhinitis, the infection reaching the antrum by means of the foramen which opens into the middle meatus of the nose; it results also from suppurative disease of a tooth socket. Symptoms. — The symptoms of the acute form are pain and soreness in the cheek, with neuralgic pains over the distribution of the second branch of the fifth nerve, fever, and tenderness of the upper teeth. Later, an abundant purulent discharge may appear from the nose, which gives marked relief to the symptoms. In the chronic form — empyema of the antrum — there are constant discomfort and neuralgia of the face, with an intermittent nasal discharge. Necrosis of the thin bony walls may occur, allowing the pus to burrow into the orbit or pterygomaxillary fossa, or it may break externallv. When the pterygomaxillary fossa is invaded, there are stiffness of the jaw and a bulging of the temporal muscle from the pus making its way upward behind the zygoma into the temporal fossa. Occasionally it points downward into the mouth near the last molar tooth. In the various forms of antral suppuration, as in other diseases of this and the other accessory sinuses, much may be learned by transillumination and the study of a well-taken .r-ray plate. For the details of these special examination methods, the reader is referred to one of the standard works on rhinology. Treatment. — The treatment of the acute form is expectant. If relief does not occur promptly through the natural channel, the cavity may be drained by breaking an opening through the thin bony plate which separates the antrum from the inferior meatus of the nose. This can easily be done by a pair of sharply curved forceps introduced into the nasal cavity beneath the lower turbinated body and forcibly thrust through the thin septum into the cavity of the antrum, then opening the forceps and withdrawing them. The cavity can be irrigated through this opening by means of a soft-rubber catheter or curved irrigating tube. In the chronic cases, in addition to nasal drainage, it is often necessary to open the antrum through the canine fossa, curette the cavity, and establish permanent drainage. If necrosis exists, a large part of the anterior wall can be removed through the mouth without external incision, the necrosed bone located and removed, and the entire cavity packed. Abscesses of the pterygomaxillary fossa should be opened above the zygoma, and through this opening a dressing forceps or other blunt instrument may be passed downward to the buccal cavity, DISEASES OF THE NOSE AND NASOPHARYNX 427 and the space opened from below on this guide. A drainage tube is then carried from the lower opening through the region of the abscess, and outward in the temporal region. Through this the diseased area can be frequently irrigated. Inflammation of the Frontal Sinus. Inflammation of the frontal sinus also results from extension of an inflammatory process upward from the nose through the infundibulum. The symptoms are severe throbbing, supra-orbital pain, and tenderness over the frontal bone. One or both sinuses may be involved. In neglected cases the bone is necrosed, pus may burrow into the orbit and cause exophthalmos (Fig. 22S), or into the cranial cavity, giving rise to meningitis or cere- bral abscess. In the chronic form a more or less constant headache. Fig. 228. — Exophthalmos from orbit infection. limited to the affected side, with evidences of slow septic absorption, may be the only symptoms. As in cases of empyema of the antrum, the presence of retained pus in the frontal sinus often may be detected by transillumination or the .r-rays. Treatment. — The' treatment should be by incision along the upper margin of the orbit near the median line, retracting the superior margin of the incision well upward, and opening the sinus by means of a chisel and mallet. A small drainage tube may be passed downward into the nasal cavity through the bony canal (which often must be enlarged) or the sinus may be packed until the inflammation has sub- sided, after which the cutaneous wound may be allowed to heal. To avoid the depressed scar which so often follows these operations, 428 INJURIES AND DISEASES OF FACE AND NECK Killian advises leaving the supra-orbital ridge, opening the cavity both above and below this bony bridge. When there is involvement of the ethmoid or sphenoid cells, these structures may be reached by carrying the original incision downward along the side of the nose, chiselling away the frontal process of the superior maxilla, and if necessary, a portion of the nasal bone. TUMORS OF THE NOSE AND NASOPHARYNX. Rhinophyma. — As a result of a neglected acne rosacea there occasion- ally develops an enormous overgrowth of the sebaceous elements of the skin, chiefly at the tip of the nose, resulting in great hypertrophy and dilatation of the vessels. Treatment. — The treatment should consist in surgical removal of the exuberant masses, followed by skin grafting. Nasal Polypus. — These tumors occur frequently, and are generally due to some chronic suppurative disease of the ethmoid cells or middle turbinated body. They occur as large or small oval gelatinous bodies, which may be so numerous as completely to fill the cavity and produce total obstruction. They are pedunculated and are attached to the mucous membrane covering the two upper turbinates. Treatment. — The treatment should consist in removal with the Jarvis or Bosworth nasal snare. Recurrence should be avoided by curing the original suppurative disease. Nasopharyngeal or Fibrous Polypus. — This growth is in reality a fibrosarcoma which arises from the periosteum of the base of the skull at the vault of the pharynx. Its growth is at first slow, and as it produces no symptoms until it is of sufficient size to cause nasal obstruction ; it is often overlooked in the beginning. It occurs generally in individuals between ten and twenty years of age. It may reach an enormous size, invading the nose, orbit, and antrum, causing great deformity of the face and often eroding the skull and involving the intracranial structures. Symptoms. — The symptoms are generally those of a catarrhal affection with more or less complete nasal obstruction and mouth- breathing; later, deformity occurs and pain from pressure on neigh- boring structures. Treatment. — The treatment should consist in early and complete excision. If the growth is small, this often can be accomplished by a snare or galvanic ecraseur introduced through the nose and manip- ulated into place by the finger introduced into the pharynx, or guided by means of the rhinoscope. When the tumor is larger it should be attacked through an external incision. By far the best procedure for these cases is the Langenbeck operation, which consists in an incision from the root of the nose downward in the nasofacial sulcus to a point just below the ala. This incision is carried to the bone, and the soft parts, including the periosteum, are raised with an elevator TUMORS OF THE NOSE AND NASOPHARYNX 429 and retracted. The nasal bone, the nasal process of the superior maxilla, a part of the lachrymal bone, and a part of the nasal cartilage, are then removed with a chisel and mallet, and an opening established through which the finger may easily be passed to the upper part of the pharynx. Through this opening, and assisted by a finger intro- duced into the pharynx through the mouth, the growth can be accu- rately located, its pedicle isolated and divided. As the growth is sometimes tabulated, it may be necessary to divide it with scissors or the knife in order to remove it. Considerable bleeding may occur not only from the divided pedicle, but also from rupture of secondary attachments. If these can be located, they should be touched with the cautery, or if necessary the wound may be packed. The packing should be removed in forty-eight hours and the cutaneous wound closed with silk or silkworm gut. If the tumor is too large to be removed by this method, partial or complete excision of the superior maxilla may be necessary. If for any reason operation is contra- indicated, Harmon Smith advises the injection into the tumor of a saturated solution of monochloracetic acid by means of a specially constructed syringe. Fig. 229. — Curtis's adenoid forceps. Adenoid Growths. — These hypertrophied masses of lymphoid tissue occur with great frequency in the vault of the pharynx and give rise to catarrhal symptoms, deafness, nasal obstruction, and infection of the cervical lymph nodes. If neglected, the disease produces a marked and characteristic deformity of the face. There is widening of the root of the nose, the mouth is held half-open, the incisor teeth may protrude, and the child gives the impression of being stupid or feeble-minded. This impression is accentuated by the often associated deafness. Treatment. — To remove these growths, the child should always be anesthetized. The mouth should be held open by a mouth-gag, and the velum drawn forward with a piece of tape passed through the nares and out of the mouth, and tied over the lip. The operator should stand on the patient's right, and with the forefinger of the left hand introduced behind the palate the growth should be located. A pair of cutting adenoid forceps (Fig. 229) are then passed along the finger to the vault of the pharynx and the growth quickly removed. After the chief masses are removed, the remaining fragments may be 430 INJURIES AND DISEASES OF FACE AND NECK scooped out by the Gottstein curet (Fig. 230). These cases bleed freely for a few moments, but the hemorrhage is easily controlled by an injection of hydrogen peroxide, 1 part to 8 parts of water. Considerable difficulty often is experienced in removing the masses about the opening of the Eustachian tube, and care should be taken to avoid wounding this structure. Enlarged Tonsils. — The tonsils are not infre- quently the seat of a pathologic enlargement, which may produce a variety of symptoms. It is more common in children, as most lymphoid tissue hypertrophies, having a tendency to diminish with advancing age. Thickness of speech, diffi- culty in swallowing, mouth breathing, naso- pharyngeal catarrh, and a tendency to acute infection are the usual symptoms. There is reason to believe that in many cases of tuber- culous infection of the cervical lymph nodes, the bacilli gain entrance through diseased ton- sils and adenoids, and recent observations have demonstrated that the original focus of infection in cases of acute and chronic arthritis, may be located in chronically enlarged tonsils. & Treatment. — Formerly surgeons performed tonsillotomy by means of the Mackenzie (Fig. 231) or some other form of tonsillotome, by which only a part of the gland was removed. Frequent recurrences led later to a more thorough removal by careful dissection. Fig. 230. — Gottstein's curet. Fig. 231. — Mackenzie tonsillotome. Recently Mathews 1 found that in children and in the majority of adults the entire tonsil could be enucleated by the finger (Fig. 232) if the mucous membrane at the summit of the tonsil between the 1 Annals of Surgery, December, 1908. DISEASES OF THE MOUTH, PHARYNX, AND JAWS 431 anterior and posterior pillars was divided and the normal line of cleavage found. This procedure is so simple, so easily performed, and so thorough, that it is to be recommended in preference to any of the older opera- tions. The patient should be anesthetized, the jaws widely separated and held by a mouth-gag. The tonsil should be grasped by a small vulsella, drawn outward, and the mucous membrane at its upper border divided with blunt scissors. The point of the closed scissors is next pushed through the cut for a short distance, and the surrounding tissues separated by partly opening the blades, after which the tonsil is easily stripped from its bed by the finger. After this enucleation, a thin strip of mucous membrane usually remains attached to its lower pole, which is divided with scissors or a wire snare. Papillomata, sarcomata, and epitheliomata occur very rarely in the nasal fossa. Tumors of the antrum will be considered in a subse- quent section. Fig. 232. — Enucleated tonsils. DISEASES OF THE MOUTH, PHARYNX, AND JAWS. Gangrenous Stomatitis (Noma). — Gangrenous stomatitis is a spread- ing gangrenous ulcer appearing on thejinside of the cheek or lip, of a debilitated person. It affects young children chiefly, and especially those who live amid unhygienic surroundings and who are recovering from infectious diseases as measles, scarlatina, and typhoid fever. Occasionally it is encountered in adults suffering from scurvy. The disease usually starts from an abrasion of the mucous membrane due to a trauma, or from a roughened tooth. The surrounding area becomes necrotic and secretes a foul discharge, which often is swallowed by the patient. The process spreads rapidly, and unless checked by prompt surgical measures results in extensive destruction of tissue and grave septic symptoms. In a few instances the gangrene perforates the cheek and may involve the nose, eyelids, ear and even the bony structures. There is usually fever, occasionally with chills, sweats, and a rapid, feeble pulse. In other cases the sepsis may be of the asthenic type. Prognosis. — The prognosis is exceedingly grave. Treatment. — The indications for treatment are to remove the necrotic area with the knife or actual cautery and to apply powerful antiseptics, as pure carbolic acid, hydrogen peroxide, or formalin. An 432 INJURIES AND DISEASES OF FACE AND NECK abundance of good food and judicious stimulation should be adminis- tered and the mouth frequently washed with antiseptic washes. Glossitis. — Glossitis is an inflammation of the substance of the tongue. It is caused by septic stomatitis, infected wounds, general toxic conditions, or mercurial poisoning. Symptoms. — The symptoms are pain and swelling in the organ and a limitation of its movements. The surface may be ulcerated from pressure on the teeth, and the swelling so great as to cause the tongue to protrude from the mouth and to interfere with respiration. The disease in some instances is limited to one side of the tongue; abscesses may form or the process may resolve. A particularly malignant form of glossitis has been described by Wright and others, which causes rapid gangrene of the organ and is apparently due to a specific micro-organism. Treatment. — Apply leeches to the submaxillary region, ice to the tongue, and, if necessary, incise over the area of greatest induration. Chronic Superficial Glossitis. — Chronic superficial glossitis is a dis- ease characterized by enlargement of the papilla 3 and the formation of cracks and other peculiar markings resembling superficial ulcerations. In other cases there is an overgrowth of epithelium, giving rise to opaque white patches (leukoplakia) or a scaly condition (ichthyosis). These conditions may or may not be associated with pain, and are important on account of the fact pointed out by Butlin, that they are very liable to be followed by cancer of the organ. Tonsillitis. — Tonsillitis is of interest to the surgeon for the reason that it is the immediate cause of peritonsillar abscesses, and often is the remote cause of chronic hypertrophy of the tonsil and glandular enlargements of the neck. Peritonsillar Abscess. — Peritonsillar abscess is a cellulitis of the tissues above and around the tonsil. It generally follows an acute Streptococcus tonsillitis, and is characterized by edema, induration, and redness of the palate immediately above the tonsil. The disease is a painful one, and is accompanied often by fever, chills, and severe toxemia. On examination of the throat with the finger, a distinct induration generally can be made out, and is the guide for the incision, which constitutes the only rational method of treatment. In making the incision the knife should penetrate the tissues for a distance of only half an inch; and if pus is not reached, a grooved director or stiff probe should be introduced into the wound and thrust in various directions until the pocket of pus is reached. Cocaine may be used, although it is rarely of much service, as the pain is due more to the pressure than the cutting. If general anesthesia is employed, the head should be allowed to hang backward over the edge of the table to avoid asphyxiation from the flow of pus into the larynx and trachea. Retropharyngeal Abscess. — Retropharyngeal abscess is a collection of pus between the spinal column and the posterior wall of the pharynx. It is due generally to suppuration of the retropharyngeal lymph nodes DISEASES OF THE MOUTH, PHARYNX, AM) JAW'S 133 from infection of the tonsils, pharynx, nose or accessory sinuses; rarely to caries of the vertebral column or to septic osteomyelitis of the body of the axis or arch of the atlas. Treatment. — The treatment should if possible be by external incision behind the sternomastoid muscle, locating the abscess by a probe or director, and enlarging the opening by a sinus-dilator or dressing- forceps. Incision through the pharyngeal wall may be necessary if the abscess points in that direction. Inflammation of the Salivary Glands. — Infection is carried to the salivary glands by the bloodvessels, lymphatics, or by the ducts. In the epidemic form, mumps, the parotid is generally affected, although the infection may occur in the submaxillary, sublingual, or as once observed by the author, in a mass of aberrant salivary gland tissue at the base of the tongue. In the ordinary septic or metastatic type of the disease, which occurs most frequently in the parotid, and which is observed during infectious diseases and following operations for grave septic conditions, the glands become swollen, hot, and tender; pain is present, and fever may develop. The process ends either in resolution or suppuration. The treatment of suppuration in these glands has been considered under the headings of Abscess of the Parotid and Angina Ludovici. Osteomyelitis of the Jaws. — In the great majority of instances osteomyelitis of the jaws is caused by suppuration around the root of a carious tooth. When this occurs the pus may loosen the tooth, find its way along the wall of the socket and infect the gum, forming a "gum-boil;" or it may infect the bone, causing an osteomyelitis, which may be limited to the region of the tooth or spread throughout it- entire structure. In the first instance it causes a small area of necrosis, through which the pus reaches the surface and collects beneath the periosteum, forming an alveolar abscess, which in turn may infect the surrounding tissues and eventually rupture externally. When the inflammation involves a large portion of the bone, the area of necrosis may be very extensive, subperiosteal abscesses form and rupture, and the periosteum eventually develops an involucrum, in the centre of which the necrosed portion of bone or sequestrum is imprisoned. Diagnosis. — The diagnosis of simple alveolar abscess is readily made by observing the features already mentioned, pain and tender- ness, and a limited area of swelling and fluctuation. In the more extensive forms generally there is a history of an ulcerated tooth, followed by swelling of the cheek, jaw, or submaxillary region, and the formation of abscesses. These continue to discharge in spite of careful treatment, and there gradually develops a thickening of the bone which may be localized or general. A probe introduced into one of the sinuses will generally detect bare bone. Treatment. — Early incision down to the bone evacuating the sub- periosteal abscess, often will abort the process. In many instances, 28 434 INJURIES AND DISEASES OF FACE AND NECK however, the case is not seen by the surgeon until necrosis has taken place. In these instances, if the process is limited in extent, free incision through the mouth, with removal of dead bone by a sharp spoon or the chisel, and subsequent packing of the cavity with iodoform gauze, constitutes the best treatment. When extensive areas of necrosis are present, drainage should be provided by free incisions, which if possible should be made from within the mouth. At a later period, when the involucrum is well formed, it may be opened and the loose sequestrum removed. Whenever it is possible, these opera- tive procedures should be carried out from within the oral cavity, as the scars from such extensive external incisions are unsightly. If, however, a number of sinuses are present, it may be necessary to attack the disease from the outside. The radical operation should not be undertaken until the sequestrum is loosened and can be removed without too great damage to the involucrum. The usual practice of simply opening down to the bone and scraping it, is of no value whatever, and serves only to increase the deformity. At best the treatment of extensive osteomyelitis of the lower jaw is unsatisfactory. When the process attacks the upper jaw, the results, as a rule, are better for the reason that usually less extensive areas are involved. TUMORS OF THE MOUTH, PHARYNX, AND JAWS. Cysts. — Cysts of the floor of the mouth may be produced by obstruc- tion and dilatation of the ducts of the mucous glands {ranida), or more rarely by dilatation of the ducts of the sublingual gland. They appear just beneath the mucous membrane of the floor of the mouth on either side of the frenum, and may grow to the size of a hazel-nut or robin's egg. Thev are semitranslucent and contain a clear mucoid fluid. Treatment. — The treatment should be by complete excision or by removal of a portion of the cyst-wall and the application of pure carbolic acid to the remaining portion. Cysts occasionally occur just beneath the mucous membrane of the lateral wall of the pharynx, and are, as a rule, of branchial origin. Their treatment should be by excision, preferably from without. Epithelioma. — Epithelioma may occur as a primary affection in the tongue, floor of the mouth, the cheeks, the gums, the palate, or in the tonsil. It may affect the jaws secondarily. As a rule, the disease appears late in life, and in the first four situations it is apt to follow severe chronic irritation from the friction of a ragged tooth or the habitual use of tobacco. Great enlargement of the lymph nodes of the neck may accompany comparatively small epitheliomata of the mouth. On the cheek the growth is apt to start near the angle of the mouth ; in the gums, around the stump of a decayed tooth. The disease is recognized by its slow growth, its indurated borders, its steady progress, and by involvement of the lymphatics. TUMORS OF THE MOUTH, PHARYNX, AND JAWS 435 Cancer of the Tongue. — Cancer of the tongue is by far the most frequently observed type of malignant disease of the oral cavity. It occurs commonly in men past middle life. It may arise spon- taneously or as a result of some chronic irritation. In not a few instances it is apparently engrafted upon a gummatous infiltration of the organ or upon a long-standing leukoplakia. Symptoms. — Several clinical types of the disease are to be recognized : first, the superficial ulcer which occurs on the lateral margin of the tongue often opposite a carious tooth; second, a gradual enlargement of one of the circumvallate papillae; third, a fissure of the tip or dorsum ; fourth, a hard nodule in the mucous membrane, which later ulcerates and resembles the first variety. All of these lesions are superficial at first, but later infiltrate the muscles and cause dense induration. When the disease is engrafted upon a leukoplakia or gumma, it is often difficult to arrive at an early diagnosis, and valuable time is Jost before radical treatment is inaugurated. In all types the growth at first is slow; later it advances more rapidly, and is accompanied by pain, difficulty in speech or deglutition, and eventual enlargement of the submaxillary lymph nodes. Prognosis. — The prognosis in cancer of the tongue, while formerly regarded as extremely unfavorable, has of late been looked upon as more encouraging, owing to its earlier recognition and more thorough methods of operation. Mr. Butlin, of London, has recently published a report of 197 personal operations in unselected cases with an operative mortality of a trifle less than 11 per cent., and 27 per cent, of cures after three years. In 70 cases, where he removed the entire contents of the submaxillary triangle, 24 (or 42 per cent.) were alive at the end of three years. In cancer in other parts of the oral cavity the prognosis is less favorable. Treatment. — The treatment should be early and complete excision, with removal of the anatomically related lymph nodes and the lymph- bearing areola tissue of the neck. These operations will be described on page 437. Sarcoma. — Sarcoma may occur in the gums, palate, jaws, tonsils, and in the adenoid tissue at the base of the tongue. In the two latter situations the disease is of that exceedingly malignant variety called lymphosarcoma. Several forms of sarcoma affect the tissues of the jaw, the least malignant of which is the giant- and mixed-cell variety of the alveolar border, called epulis. Periosteal sarcoma, spindle- or round-cell, may occur on any part of the superior maxilla, but is more common on its anterior surface or alveolar process. Both the periosteal and the central variety may affect the mandible. Slow- growing localized or diffuse hypertrophy of the jaw has been twice observed by the writer which, upon gross inspection, resembled a normal formation of new bone, but which strongly suggested chondro- sarcoma under the microscope. Further observation made it probable that the disease was that described in another chapter as leontiasis. 436 INJURIES AND DISEASES OF FACE AND NECK Sarcomata originating in the mucoperiosteum of the antrum are common, and their growth is often rapid, bulging the walls of this cavity and encroaching upon the nasal chamber, the orbit, the spheno- maxillary space, and the mouth. "Sarcoma of a tooth-follicle occurs only in children, and is particu- larly apt to involve the germ of the first permanent molar" (Bland- Sutton). It is recognized by its rapid growth and the other character- istics of sarcoma already mentioned. The treatment is early and complete removal. Adenoma. — An encapsulated adenomatous tumor occasionally occurs in the tissues of the soft palate. It is round or oval in shape, and may attain the size of a hen's egg. It is not malignant. It should be removed by enucleation. A rare and exceedingly rapid growing tumor of the palate, resembling the above-mentioned palatine adenoma, may occasionally be encountered, which is extremely malignant. It also occurs in the region of the gums, probably from aberrant masses of salivary gland tissue. It is classed by Volkmann among the endotheliomata. Osteomata, papillomata, angiomata, lymphangiomata, and lipomata occasionally occur in these regions, but possess no special features. Their treatment has already been considered. Odontomata and Dental Cysts. — These tumors are often loosely spoken of as dentigerous cysts. They may occur in either jaw, and are much more frequent than is generally supposed. Bland-Sutton has classified these tumors as follows: An epithelial odontome is a tumor growing from the enamel-organ of the tooth, and made up of small cysts containing a brownish fluid. It is encap- sulated and may distend the bone. A follicular odontome is an expanded tooth-follicle containing a viscid fluid and an imperfectly developed tooth. A fibrous odontome is a greatly thickened tooth-sac which forms a dense layer of fibrous tissue around a tooth, preventing its eruption. A compound follicular odontome is a tumor made up of cementum, dentine, and often a large number of imperfectly developed teeth, an incomplete ossification of the tooth-capsule. A radicular odotome grows from the root of the tooth, and is made up of dentine and cementum, but no enamel, as the tumor develops after formation of the crown of the tooth, which does not undergo change. A com- posite odontome is an irregular bony tumor occurring in the jaw-bone or in the antrum, made up of cementum, enamel, and dentine. It may reach a large size. These tumors are often regarded as osteomata, osteosarcomata and other forms of new growth. The true diagnosis is rarely made before the operation. They should be removed with a chisel and mallet or with bone-forceps. In the cystic variety it is often only necessary to open the cavity, curet, and pack. Gummatous Infiltration. — Gummatous infiltration of the tongue, tonsil, palate, and pharyngeal wall occurs frequently, and must be OPERATIONS ON TONGUE, MOUTH, PHARYNX, AND JAWS 131 distinguished from new growths. It occurs first as a rapidly develop- ing tumor, which soon breaks down, leaving large necrotic ulcers and often resulting in extensive losses of tissue. In the tongue the process is often a slow one; in the palate, tonsil, and pharynx it is frequently one of great rapidity, enormous sloughs occurring in a few days follow- ing the first symptoms. These lesions are characterized by absence of pain, by their rapid destruction of tissue, and by their prompt improvement under antisyphilitic treatment. Tuberculous Ulceration. — Tuberculous ulceration of the tongue is rare, and generally is secondary to lung tuberculosis. It occurs on the side near the tip, as a ragged, undermined ulcer surrounded by soft tuberculous nodules. In other cases it is simply a superficial erosion surrounded by a slightly elevated hard border. There is, as a rule, no deep or massive induration. Tuberculous ulcerations in other parts of the oral and pharyngeal cavities are extremely rare. They are often the seat of spontaneous pain, differing thereby from the syphilitic lesions. OPERATIONS ON THE TONGUE, MOUTH, PHARYNX, AND JAWS. Removal of the Tongue. — Partial or complete removal of the tongue may be accomplished through the mouth ("Whitehead) by the sub- maxillary operation (Kocher) or by one of the several methods by which access to the region is gained by division of the jaw. In all operations for malignant disease of the tongue one should strive to imitate in thoroughness the modern operation for breast cancer. Thus, in small superficial lateral erosions without enlarged glands, one-half of the tongue should be removed, together with the submaxillary gland, all the areolar tissue, and lymphatics of the submaxillary triangle. Where the disease is more advanced, with palpable lymph nodes, the entire lymph-bearing areola tissue of the lateral aspect of the neck should be removed, as well as the sub- maxillary gland, the sternomastoid muscle, and often the internal jugular vein. When the disease approaches or passes the midline of the tongue, the entire organ should be removed. Where the disease is at all advanced, that portion of the floor of the mouth containing the infected lymph channels should be thoroughly removed with the submaxillary tissues. It is only by these radical procedures so strongly advocated by Crile that satisfactory results can be expected. Before any operation on the tongue the patient should have all carious teeth filled or removed; and for several days prior to the operation the oral cavity should be frequently disinfected by washes of hydrogen peroxide, listerine, or boric acid. Ether should be admin- istered by means of Crile 's nasal tubes and the pharynx packed with gauze; or, as suggested by Butlin, a preliminary thyrotomy may be employed for anesthesia. If the Whitehead procedure is followed, 438 INJURIES AND DISEASES OF FACE AND NECK the jaws should be held apart by a mouth-gag; the tongue should next be firmly grasped by a vulsellum forceps and drawn upward and out- ward. It should then be severed from its connections at the floor of the mouth and hyoid bone by means of heavy, blunt-pointed scissors. The lingual arteries should be clamped as they are cut, and subse- quently ligated with chromicized catgut or silk. If the Kocher method is employed, an incision should be made along the course of the digastric muscle from the symphysis of the jaw to a point just below the lobule of the ear, dividing the skin, superficial fascia, and the platysma muscle. The flap is dissected from the deeper parts and drawn upward with a retractor. The deep fascia is next divided in the line of the original incision, and this with the submaxillary and sublingual glands, the lymphatics, and the areolar tissue of the part, thoroughly removed. The lingual artery is found beneath the hyo- glossus muscle and ligated. If the entire tongue is to be removed, the lingual artery on the opposite side is also exposed and ligated. The floor of the mouth is then divided by an incision along the ramus of the jaw, and the tongue drawn downward through the wound by means of a vulsellum forceps or sharp hook. Partial or complete excision can then be performed with scissors. After removal of the diseased area the mucous membrane of the floor of the mouth should be partly united, the external wound packed or partly closed with sutures and drained. As in all other mouth operations, scrupulous care should be taken to limit the local infection and to remove its products. The patient should be fed by the rectum for one or two days, after which food should be administered by means of a stomach-tube. The cavity of the mouth should be washed every hour at least, with weak hydrogen peroxide, boric acid, or myrrh wash. Von Langenbeck's Operation for Removal of the Tongue, Tonsil, Floor of the Mouth, and Palate. — An incision is made from the angle of the mouth to the junction of the anterior margin of the masseter muscle with the lower border of the mandible, and from this point downward and forward toward the great cornu of the hyoid bone. The lower half of the incision is carried down to the sheath of the vessels and the external carotid ligated. The submaxillary gland and the lymphatics of the submaxillary triangle are next removed, after which the upper part of the incision is carried through the cheek to the bone. A Gigli saw is then passed behind the ramus of the jaw through the floor of the mouth and the bone sawed in an angular fashion to prevent subsequent displacement. The two extremities of the divided bone are then retracted by sharp hooks and the diseased tissues readily removed by scissors or the knife. After this is accomplished the mucous membrane should be united whenever this is possible, the bone drilled and sutured together with chromicized catgut, and the cutaneous wound accurately coapted with sutures or hare-lip pins. This operation gives the best exposure of the parts, but is open to the objection that the bone occasionally fails to unite and necrosis may result. OPERATIONS ON TONGUE, MOUTH, PHARYNX, AND JAWS 439 When the disease is situated near the tip or is bilateral, division of the jaw in the midline (Sedilot's operation) is to be recommended. Cheever's Lateral Pharyngotomy. — An incision is made along the anterior border of the sternomastoid muscle from the lobule of the ear to a point opposite the cornu of the thyroid cartilage, and the structures divided down to the deep fascia, which is opened. The external jugular and temporofacial veins are divided between two ligatures and the carotids and the deep jugular retracted outward. The digastric, stylohyoid, and stylopharyngeus muscles are divided or retracted and the glossopharyngeal and hypoglossal nerves avoided. The lateral wall of the pharynx may then be incised on a sound or finger introduced through the mouth, and any growth in the region of the tonsil or superior laryngeal aperture removed. After careful hemo- stasis and disinfection, the wound in the pharynx should be tightly closed with two layers of fine silk and the superficial structures united, drainage being provided for at the lower angle of the wound. Removal of the Upper Jaw. — After preliminary ligation of the external carotid an incision should be made along the lower border of the orbit, the nasofacial sulcus around the ala of the nose to the median line, and from there downward through the upper lip to the mouth. The incision should be carried to the bone and the flap retracted outward, exposing the entire anterior surface of the superior maxilla. The central upper incisor tooth on the affected side should then be drawn and the alveolar process and hard palate divided by means of a saw introduced through the anterior nares or by a heavy bone-forceps. The nasal process is next divided by the forceps and the zygoma cut near its maxillary extremity. The bone should then be grasped by a strong pair of lion-jawed forceps and wrenched from its posterior attachments. Considerable bleeding is apt to follow this procedure, largely from the pterygoid plexus of veins, which must be controlled by packing. After this has been accomplished the parts should be thoroughly inspected for evidences of disease, which, if found, can easily be removed by the forceps or bone-curet. The skin flap should be replaced and united with silkworm-gut or silk sutures, with or without one or more hare-lip pins in the upper lip. Removal of the Lower Jaw. — To remove one-half of the lower jaw, make a vertical incision through the lower lip to the symphysis of the chin, then along the inferior border of the horizontal ramus to the angle, then upward for a short distance toward the lobule of the ear. The soft tissues should be removed from the bone by dividing the mucous membrane along the alveolar border and severing the muscular attachments with an elevator. The symphysis is next divided by a Gigli saw. The tissues forming the floor of the mouth should then be cut close to the bone and the ascending ramus exposed by an incision along the mucous membrane and drawing upward of the musculocutaneous flap. When the entire half of the bone is exposed the horizontal ramus is depressed until the attachment of the temporal 440 INJURIES AND DISEASES OF FACE AND NECK muscle can be seen and divided. The internal pterygoid muscle should be detached from the inner surface by an elevator, the inferior dental vessels and nerves severed, and the capsule of the joint exposed and opened from in front. In disarticulating, care should be taken to avoid wounding the internal maxillary artery, which lies between the neck of the jaw and the internal lateral ligament. The soft parts should then be replaced and united with hare-lip pins, silk or silkworm gut, and union of the mucous membrane within the mouth brought about as far as possible by stitching with catgut. If it is necessary to remove the entire mandible, the second half may be taken out in the same manner. Partial resection of the lower jaw is frequently necessary for osteomyelitis or epulis, and generally can be effected through the mouth without external incision. DISEASES OF THE LARYNX, TRACHEA, AND ESOPHAGUS. Injuries of the Larynx, Trachea, and Esophagus. — Injuries of the larynx, trachea, and esophagus have been considered in the earlier part of the chapter. Edema of the Glottis. — Edema of the glottis is a swelling of the mucous membrane and submucous areolar tissue about the larynx and vocal cords, giving rise to dyspnea, stridor, loss of voice, and often complete respiratory obstruction leading to sudden death. The causes of edema of the glottis are acute laryngitis from catarrhal or septic inflammation of the neighboring structures, as diphtheria, peritonsillar abscess, angina Ludovici; from the inhalation of live steam, irritating or heated vapors; from traumata, tuberculous or syphilitic ulcers, new growths, chronic cardiac or renal disease. Treatment. — The treatment of this condition is, in the milder cases, by applications of a solution of cocaine or adrenalin to the larynx, steam inhalations, and the internal administration of cathartics and aconite. Whenever the symptoms threaten complete obstruction or are progressive in character, intubation of the larynx or tracheotomy should be performed. Foreign Bodies in the Larynx or Trachea. — Particles of food and other solid bodies occasionally are aspirated from the mouth into the air passages. The accident occurs most frequently in children and in vomiting patients during or after the administration of a general anesthetic. The foreign body may lodge in the larynx, trachea, or one of the bronchi. Foreign bodies in the larynx give rise to an immediate fit of violent coughing, spasm of the glottis, cyanosis, and often vomiting, during which the foreign body, if small, may be expelled. If the body lodges in the trachea the symptoms are at first similar, but are soon relieved if the irritating substance becomes fixed below the larynx. Coughing, however, may cause a renewal of the dyspnea and spasm by again driving the intruder upward against the vocal cords. If the foreign DISEASES OF THE LARYNX, TRACHEA, AND ESOPHAGUS 441 body passes into one of the bronchi (generally the right), more or less obstruction may develop to the ingress and egress of air, which is apparent by auscultation; and if the obstruction remains, pneumonia, lung abscess, or gangrene may result, or erosion of a bloodvessel and fatal hemorrhage. Exceptionally a foreign body may remain for years in the lung without giving rise to untoward symptoms. Treatment. — Foreign bodies in the upper part of the larynx fre- quently can be seen by the laryngeal mirror and removed by forceps. If the body lies below the vocal cords, give ether and invert the patient, striking the back violently with the flat of the hand. This may dislodge the body and it may be expelled. If this is unsuccessful, perform high tracheotomy, holding the edges of the tracheal wound wide apart, and repeat the process or use long, thin-bladed forceps. Foreign bodies in the lower part of the trachea or primary bronchi occasionally may be reached by forceps through a low tracheotomy wound. If the body is lodged in one of the smaller bronchi, the prog- nosis is exceedingly grave. During the past few years the method of removing foreign bodies from the trachea and bronchi by means of Killian's bronchoscope has steadily grown in favor. This instrument is simply a long metal tube highly polished on the inside, which is carried into the trachea or bronchi through the mouth or through a tracheal wound. A strong column of light from a frontal electric lamp enables the operator to detect the presence of the foreign body, which then can be removed by specially constructed forceps or hooks. Considerable technical skill is required, but a number of cases are on record where foreign bodies have been located and removed from regions as remote as the second division of the bronchial tube (Fig. 233). Foreign Bodies in the Esophagus. — Foreign bodies in the esophagus are much more common, as coins, marbles, false teeth, and many other articles frequently are swallowed and lodge in the esophagus. Symptoms. — The symptoms of a foreign body in the esophagus are localized pain, dysphagia, and salivation. The position of metallic bodies can be located by the metal esophageal bougie or the .i*-rays. The location of other bodies usually can be determined by passing bougies of various sizes to the point of obstruction. The three narrow- est parts of the tube are at its commencement, about three inches below this point, and at the esophageal opening in the diaphragm. Treatment. — Swallowing quantities of soft bread, mush, or potato occasionally will carry a foreign body into the stomach. Coins often may be removed by the coin-catcher (Fig. 234); other substances by the esophageal forceps or the horse-hair probang (Fig. 235), which should be introduced closed beyond the foreign body, opened, and with- drawn. If these measures fail, perform external esophagotomy and attempt removal by the forceps. This is usually successful for bodies lodged in the first six inches of the tube. When the foreign body is lodged deep in the thoracic portion of the esophagus the esophagoscope may be employed. When this is not available, have 442 INJURIES AND DISEASES OF FACE AND NECK the patient swallow a long piece of silk thread, the upper end of which is secured bv tying to the ear or to a button on the patient's clothing. Fig. 233. — Upper bronchoscopy. Dorsal position. THEKNV rSCBEEREfi CO.N.y, Fig. 234. — Coin-catcher. Fig. 235. — Horse-hair probang. When there is reason to believe that the thread has passed into the stomach, perforin gastrostomy, pick up the thread on a curved probe introduced into the stomach, and with this draw downward a piece DISEASES OF THE LARYNX, TRACHEA, AND ESOPHAGUS 443 of heavy braided silk or bass line, in centre of which is tied a mass of gauze, a rubber or metal cup. This contrivance is drawn downward into the stomach in the hope of bringing with it the foreign body. The author on one occa- sion w r as in this way able to re- move a detached metal bulb from an esophageal bougie lodged between two dense strictures in the thoracic por- tion of the esophagus. (The Fig. 236. — Bulb and parachute snare. Fig. 237. — Whalebone sound with adjustable ivory tips. bulb and the "parachute snare" are shown in Fig. 236.) If this fails, resort must be had to a transthoracic esophagotomy. 444 INJURIES AND DISEASES OF FACE AND NECK Stricture of the Esophagus. Stricture of the esophagus is generally due to swallowing some corrosive substance, as lye or strong acid, to the irritation of a foreign body, to the healing of ulcers, to new growths, to the pressure of an aortic aneurism, or to hysteric spasm. When due to the swallowing of a corrosive sustance (the commonest cause), the symptoms are at first those of an acute esophagitis: pain, dys- phagia, and salivation. Later these symptoms disappear, and the patient seems well and free from discomfort of any kind. This period of calm is succeeded by a gradually increasing difficulty in swallowing until only fluids can be taken. Wasting rapidly follows, and when fluids are no longer swallowed emaciation becomes extreme. When the stricture is due to the growth of a tumor or the pressure of aneurism, the early irritative symptoms are wanting, and an .r-ray plate will often reveal the presence of a tumor. Diagnosis. — The diagnosis of stricture of the esophagus generally can be made from the symptoms just mentioned, but it is desirable also to determine the location of the point of narrowing, and the presence or absence of a proximal dilatation of the tube. The former can be accurately ascertained by use of the esophageal bougie, the latter by an .r-ray plate after the swallowing of bismuth suspended in gruel. The caliber of the stricture often can be determined by the use of olive-pointed bougies of various sizes (Fig. 237). When it is impossible to pass any instrument through the stricture, owing to the presence of a proximal dilatation or sacculation of the esophagus, or because of a tortuous opening through the strictured area, the examination may be facilitated by the use of Mixter's tunnelled bougies or bulbous sounds. Five or six feet of silk thread is swallowed through a glass feeding-tube with a goblet of water. This usually passes the stricture, enters the stomach and in time extends well downward into the small intestine — allowing considerable tension to be made upon it by traction upon its upper end. When thus drawn tense, it is passed through the eye of the bougie or bulb, and the latter guided through the stricture. In this way the number of strictures and the caliber of each can be determined in the majority of instances. Treatment. — The treatment should be dilatation by means of flexible gum-elastic esophageal bougies passed every second day until one 40 or 50 mm. in circumference can be introduced, after which the instru- ment should be passed by the patient at least once a week. W T hen gradual dilatation is impossible, and especially in those cases in which starvation is rapidly progressing, gastrostomy should be performed and the patient generously fed through the fistulous opening. When strength returns, a thread should be swallowed, and by this, a piece of strong braided silk or fish-line carried through the esophagus from the mouth downward and out at the gastrostomy wound. With this line the stricture can be "sawed" to any extent, care being taken during the sawing to protect the mucous membrane DISEASES OF THE LARYNX, TRACHEA, AND ESOPHAGUS lb". of the stomach and throat by means of a metal tube for the former and a perforated tongue-spatula for the latter. The presence of a fusiform metal bulb attached to a piece of piano-wire (Fig. 238), held firmly against the stricture during the cutting, keeps the stricture on the stretch and prevent- injury to other parts by passing through the stricture as soon as it is sufficiently enlarged. When all strictures are divided in this way to Xo. 50 of the French scale, a rubber tube of the same size may be drawn through the stricture by means of a piece of heavy silk or twine attached to either end, and left in position for several days. This checks hemorrhage, and if the tube is of full size, introduced while on the stretch and allowed to relax after it is in place, a certain amount of continuous dilatation is maintained. If this tube is employed.it should be removed at the end of twenty-four hours, after which a full-sized bougie or bulb should be passed every Fig. 23S. — Metal bulb to facilitate the sawing of esophageal stricture. second or third day for a fortnight, and at least once a month thereafter for a year. When a proximal dilatation is present it will be necessary to employ a tunnelled bougie on a thread, until the dilated esophagus has contracted to its natural size. Esophageal Diverticula. — Esophageal diverticula may be congenital or acquired. The acquired variety generally are due to stricture, to traction on the tube by neighboring inflammatory processes, or to hernia of the mucous membrane through an abnormally weakened muscular coat from inside pressure. The latter variety is the common- est and usually occurs during adult life. It is situated at or near the junction of the pharynx and esophagus, the pouch projecting back- ward, and subsequently extending downward and to one side. Symptoms. — The symptoms of an esophageal diverticulum are dysphagia, the frequent regurgitation of large amounts of mucus, and the presence of a swelling in the neck during the process of swallow- 446 INJURIES AND DISEASES OF FACE AND NECK ing a meal. In these cases the patients are unable to swallow solid pieces of food, and learn to subsist chiefly on fluids and semisolids, as mush, custard, and scraped beef or finely hashed meat. The first food taken at a meal is swallowed with difficulty and generally passes into the diverticulum, after which swallowing is easier, the food passing over the filled diverticulum into the stomach. An esophageal bougie passes into the diverticulum when it is empty; when, however, it is filled with food, the bougie often may be introduced into the stomach. The diagnosis can be easily established by an a--ray plate after swallowing bismuth gruel. It also can be confirmed by the method of Plummer, which consists in passing a tunnelled bougie on a previously swallowed thread. If the thread is held loosely the bougie passes into the diverticulum, and is arrested when it reaches the bottom of the sac. If the thread is then drawn taut the bougie rises until its tip is on a level with the opening into the esophagus. It can then be easily passed along the tense thread guide into the stomach. Careful measurements will enable the surgeon by this method to estimate the depth of the pouch. Treatment. — When the diverticulum is situated in the neck, it can be exposed by the ordinary incision for external esophagotomy, the pouch removed, the esophageal wound sutured with two or more layers of fine silk or chromicized catgut, and the external wound closed with a rubber tissue drain. In deep thoracic diverticula little can be done until the difficulty in swallowing becomes extreme. In these cases gastrostomy is indicated. TUMORS OF THE LARYNX. Both benign and malignant tumors occur in the larynx. Of the former, papilloma and fibroma are the most common. Papillomata. — Papillomata occurs generally before middle life, and are located on the vocal cords, just below the anterior commissure, or in the pyriform sinus. They appear as pedunculated or sessile, wart-like masses, which show no tendency to infiltrate the surrounding tissues. In adult life they are generally single, in childhood they are often multiple, and may cover the ventricular spaces, vocal cords, and extend into the trachea. Fibromata. — Fibromata may be of the hard or soft variety. They are most frequently encountered on the vocal cords or at the anterior commissure. They are covered by intact mucous membrane, and may be pedunculated. Epitheliomata. — Epithelioma^ occur later in life and their malig- nancy depends largely upon their location. Those situated wholly within the larynx I intrinsic cancer), as on the true or false cords in the ventricles, or in the subglottic space, grow slowly, rarely infect the lymphatics, and almost never give rise to visceral metastasis. Those occurring at the superior aperture of the larynx (extrinsic cancer) TUMORS OF THE LARYNX 447 grow more rapidly, infect the lymph nodes at an early period, are often spread to the tissues of the pharynx and tongue. In more than half the cases, epithelioma takes its origin from the vocal cord. It first appears as an elevated oval nodule, a small warty growth, or a superficial ulceration, and is with difficulty differentiated from a fibroma, benign papilloma, or non-malignant ulceration. The occur- rence, however, of a peripheral hyperemia and edema, and a limitation in the mobility of the cord in phonation, is strongly suggestive of an infiltrating growth. Symptoms. — Symptoms of tumor of the larynx are a progressively increasing hoarseness, cough, and dyspnea. As these symptoms are common to many affections of this organ, the diagnosis can only be established by a lar^ngoscopic examination. If after laryngoscopic examination doubt exists as to the nature of the growth, a generous fragment should be removed with forceps and subjected to microscopic examination. Prognosis. — The prognosis of the disease varies widely. The benign neoplasms, as a rule, grow slowly, and if located on a part of the mucous membrane remote from the vocal cord may give rise to no symptoms. Tumors arising from the vocal cord or at a point just above or below the cord, cause hoarseness at all times; and a varying degree of cough and dyspnea, depending upon the amount of irritation produced. Often in the benign cases the disease seems to remain stationary for months and years. In epithelioma on the other hand, there is, as a rule, a progressive increase in all symptoms as the tumor advances. In addition to the hoarseness and cough, pain develops and later signs of stenosis, with redness, edema, and tenderness over the thyroid cartilage indicating the presence of ulceration or necrosis. At this period there is an abundant expectoration of a foul, bloody or puru- lent mucus, which may by inhalation give rise to a terminal septic pneumonia. Treatment. — Small papillomata of the larynx often may be made to disappear by inhalations of a spray of alcohol (Delavan) or by the application of caustic agents. The best method of treatment, however, is by removal with cutting forceps under guidance of the eye by means of a laryngoscope. This, however, should only be under- taken by a skilled laryngologist. Subglottic tumors are reached and easily removed by median thyrotomy. Intrinsic cancer of the larynx in its earliest stages often may be successfully removed by thyrotomy (Butlin) or by partial laryngectomy. Total laryngectomy is, however, the operation of choice in all cases of malignant disease of the organ in which the growth involves the opposite side of the larynx, the commissure, or where there is evidence that the cartilage is eroded. In advanced cases it should always be accompanied by extensive bloc dissection of the lymphatics and the lymph-bearing areolar tissue of the neck. This method should also be adopted in malignant growths of the superior aperture of the larynx, as in these cases the disease 44S INJURIES AND DISEASES OF FACE AND NECK quickly involves the lymphatics and pursues a much more rapid course. In advanced inoperable cases, radium or the .r-rays may be employed, and where dyspnea from stenosis exists, tracheotomy is indicated. Tuberculous and Syphilitic Ulcerations. — Tuberculous and syphilitic ulcerations of the larynx are of frequent occurrence. The former begin in the arytenoids or vocal cords, and gradually extend to the other tissues, including the pharynx. The latter begin by a gummatous infiltration of the epiglottis or cords, which soon breaks down, forming typical syphilitic ulcers which extend to the neighboring tissues. Perichondritis and necrosis of the cartilages may occur. Obstinate cicatricial stenosis frequently follows syphilitic ulceration. The treat- ment is purely medical until stenosis occurs. TUMORS OF THE TRACHEA. New growths of the trachea are rare. Of the benign growths papillomata and fibromata are the most common. Lipomata , chondro- mata, and adenomata have been observed. Intratrachial struma or aberrant masses of thyroid tissue also occur in the trachea, chiefly on the posterior wall. Of the malignant growths, carcinoma and sarcoma are to be con- sidered. The former occurs with greater frequency, the proportion being two to one. Symptoms. — Tracheal tumors rarely give rise to symptoms until stenosis occurs. Dyspnea is generally the first symptom. Later there is cough with increased dyspnea and cyanosis on exertion. Papillomata not infrequently develop just above the tracheal opening in patients after tracheotomy, and who for any reason are obliged to retain the tube for a long period of time. The treatment is by an extensive tracheotomy or laryngotracheotomy with removal of the growth if benign. In malignant cases more or less extensive tracheal resections may be necessary. TUMORS OF THE PHARYNX AND ESOPHAGUS. Epithelioma. — Epithelioma occurs in the pharynx near the base of the tongue and in the upper part of the esophagus. Cancer. — Cancer of the thoracic portion of the esophagus is apt to be of the glandular variety, and affects chiefly the lower portion of the tube as it passes through the diaphragm. Diagnosis and Treatment of Tumors of the Pharynx and Esophagus.— Tumors of the lower pharynx and esophagus rarely give rise to symp- toms until they extend to other organs, as the larynx, or cause obstruc- tion. The first symptom is generally dysphagia, which gradually increases until typical symptoms of stricture are produced. The extension of a pharyngeal growth to the larynx is indicated by dyspnea PLATE XV Ulcerating Secondary Carcinoma of Lymph Nodes of Neck. Probably arising from some unrecognized foeus in pharynx or esophagus, or possibly from a small branchial epithelioma. (Lumiere photograph.) OPERATIONS ON LARYNX, PHARYNX, AND ESOPHAGUS 449 and loss of voice. Pain occurs as a later symptom. Benign tumors when accessible sometimes can be removed by lateral or infrahyoid pharyngotomy or by external esophagotomy. The treatment of malignant tumors of the esophagus has until quite recently been unsatisfactory. At a recent meeting of the International Congress of Surgery, Gluck, of Berlin, exhibited a number of cases of advanced malignant disease of the larynx, pharynx, and esophagus successfully operated upon by thorough local removal and extensive bloc dissec- tions of the lymphatics of the neck. Carcinoma of the thoracic portion of the esophagus may be approached by a transthoracic operation, by the use of a negative pressure cabinet or better, by positive pressure anesthesia by the intratracheal method. Torek has recently reported a successful case. Sarcomata may occur in the pharynx, very rarely in the larynx or trachea, except by extension from other regions. Angiomata, lipomata, and myomata have been observed. OPERATIONS ON THE LARYNX, PHARYNX, AND ESOPHAGUS. Thyrotomy. — This operation is undertaken for the prompt relief of sudden edema of the glottis or other forms of respiratory obstruction occurring at the rima glottidis. In an emergency it may be performed by plunging the blade of a pocket knife through the lower part of the thyroid cartilage and cricothyroid membrane, and separating the edges of the wound by turning the blade sidewise or inserting the handle of the knife, a key, or bent hairpin. Performed in this manner there is always danger of hemorrhage from a branch of the cricothyroid artery. Complete Section of the Thyroid Cartilage. — Complete section of the thyroid cartilage in the median line is employed for examination of the interior of the larynx and for the removal of intralaryngeal growths. The patient should be placed in the Trendelenburg posture and a preliminary tracheotomy performed, with closure of the trachea by means of a sponge inserted above the canula or by the use of a Hahn tube. An incision should then be made in the median line from the hyoid bone to the second or third ring of the trachea, dividing all structures down to the cartilage. The larynx should then be opened, the two halves separated, and the parts inspected. After carrying out the necessary intralaryngeal procedures the cartilages may be brought accurately together and held by several sutures, or the wound packed with sterile gauze. The tracheal tube should be retained until the danger from edema or hemorrhage has passed. Tracheotomy. — In the majority of instances in adult patients, local anesthesia should be employed for this operation. In children, especially where marked dyspnea is present, general anesthesia, preferably chloroform, should be used. An incision should be made 29 450 INJURIES AND DISEASES OF FACE AND NECK in the median line over the trachea, the sternohyoid and sternothyroid muscles drawn outward by retractors, and the trachea exposed above or below the isthmus of the thyroid. Several large veins are often encoun- tered both above and below the deep fascia, which should be secured and divided between ligatures. When the trachea is bared, clearly exposing the rings, and when all hemorrhage is arrested, a vertical incision should be made into the tube, the edges of the wound separated Fig. 2.'jU. — Tracheal dilator. by a tracheal dilator (Fig. 239), and a tracheal tube (Fig. 240) intro- duced and held securely in place by a tape passed around the neck. One or two cutaneous sutures may be inserted or the wound packed with gauze. Following the tracheotomy, patients whould be kept in a warm room and the head of the bed surrounded by a tent of blankets to avoid draughts of air (Fig. 243). A croup kettle or steam atomizer is of advantage in some cases to render the inspired air moist and warm. The patient should be carefully watched, the tube regularly Fig. 240. — Tracheal tube. cleaned, the wound frequently dressed, and the inspired air at first filtered by passing through several layers of loose gauze. There is a fairly high mortality following tracheotomy, from the frequent occur- rence of septic pneumonia. This always should be considered in performing the operation preliminary to other operations on the upper air passages. The pneumonia in these cases is largely due to the OPERATIONS ON LARYNX, PHARYNX, AND ESOPHAGUS 451 inhalation of blood during the operation and of septic material after recovery from the anesthetic. Great care should, therefore, be used to avoid both of these dangers. Intubation of the Larynx. — This operation consists in the introduc- tion into the larynx of a metal or gutta-percha tube so constructed Fig. 241. — Tracheotomy tube in position. as to fit its lumen, and provided with a flange on its upper extremity to rest upon the false cords. The operation is performed by a special set of instruments devised by O'Dwyer (Fig. 244). No anesthetic is required in ordinary cases. The patient sits or is held in front of the operator with the mouth widely open. The surgeon then adjusts Fig. 242. — Konig's spiral canula. the tube to the introducer, passes his left forefinger over the base of the tongue to the epiglottis, which, with the base of the tongue, is drawn well forward. The tube is next passed into the pharynx and the tip directed into the laryngeal entrance by elevating the handle of the introducer. As soon as the tube passes the glottis, 452 INJURIES AND DISEASES OF FACE AND NECK it is pushed from the introducer by means of a lever device on the handle and the tube pressed well downward by the forefinger of the left hand. In removing the tube, the orifice is located with the finger, the tip of the extractor passed into its lumen, the jaws opened, and both tube and extractor removed. Laryngectomy. — The operation is performed in two stages. Under local anesthesia a median incision is made extending from the cricoid to the sternal notch. The muscles are separated, exposing the isthmus of the thyroid, which is doubly ligated and divided. The separated edges are pushed to each side and the trachea freely exposed. A Fig. 243. — Tracheotomy tent showing patient after total laryngectomy. low tracheotomy is then performed and the canula introduced, after which the upper part of the incision is united with silkworm-gut sutures, and the peritracheal space generously packed with iodoform gauze both above and below the canula (Fig. 245). The wound is dressed and the patient placed under a tracheotomy tent (Fig. 243), into which a small amount of steam is introduced by means of a croup kettle. The external opening of the tracheal canula is constantly covered with four or five layers of gauze which may be dampened with boric acid solution with a view to filtering the air which enters the trachea. A special day and night nurse attends the patient. OPERATIONS ON LARYNX, PHARYNX, AND ESOPHAGUS l.j.'! About ten days after the preliminary operation, if the patient has a normal temperature and is not suffering from cough or excessive tracheal secretion, the secondary operation is undertaken. Chloro- form is administered through the tube until the patient is anesthetized, after which its administration is continued in the same manner, or colonic etherization is employed by means of the Sutton apparatus. The use of scopolamine (gr. T ^ ¥ ) and of morphine (gr. |) one-half hour before operation is a decided advantage in these cases, as it not only diminishes to a considerable extent the amount of anesthetic required, but in addition it minimizes tracheal secretion, lessens the m| t^^Wtk" Hi I mmlQ j 4 : ■ ;■'■; ^•••^»»g M i Fig. 244. — O'Dwyer's intubation instruments: A, tube with obturator; B, tube; C, obturator; D, metal gauge; E, mouth-gag; F, introducer; G, extractor; H, silk cord. (Fowler.) postoperative vomiting, and insures a period of from one to four hours of freedom from restlessness after the operation, a time when most laryngeal cases are coughing, and increasing thereby the always- present tracheal irritation. Recently the author was able to perform a total laryngectomy under local novocaine anesthesia, except for a few minutes, while the esophagus wound was being sutured, when chloroform was employed. This procedure is to be advised in an intelligent patient with a high degree of self-control. The patient is placed on a flat table with the head well extended. An incision is made from the body of the hyoid downward to the 451 INJURIES AND DISEASES OF FACE AND NECK upper limit of the former cut. From the upper extremity of this incision two lateral incisions are made in an upward and outward direction, extending to the anterior borders of the stemomastoid muscles. The two triangular flaps are turned outward, the sternohyoid muscles divided just below their attachment, and the sternothyroids detached from the cartilage. The two superior thyroid arteries are next located and ligated. The superior laryngeal nerves are cut and all lymph nodes and neighboring lymph-bearing areolar tissues are removed. The attachments of the inferior constrictors are next divided and the posterior surface of the cricoid partly separated from the esophagus by blunt dissection. Fig. 245. — Preliminary tracheotomy with gauze packing about trachea. When the larynx is thoroughly skeletonized, the trachea is severed just below the cricoid, and its distal extremity immediately packed tightly with gauze, completely preventing the entrance of blood or pharyngeal mucus. The forefinger of the left hand is next introduced into the upper or laryngeal segment of the tube and the larynx gently raised from the esophagus, any remaining attachments being separated by gauze sponges (Fig. 246). When the larynx is thus completely separated from the esophagus, the tips of the thyroid cornua are divided, the thyrohyoid membrane incised, and the larynx removed. The pharyngeal wound is then packed with gauze to prevent excessive OPERATIONS ON LARYNX, PHARYNX, AND ESOPHAGUS 455 contamination of the wound, and the parts carefully inspected for evidences of remaining disease. The oval pharyngeal wound is next tightly closed by two layers of suture, the first of plain catgut, the second of chromic catgut. After closure of the pharyngeal opening, the entire upper wound is temporarily packed with wet formalin gauze, while the tracheal stump is prepared for closure. This is accomplished by dissecting out or destroying with cautery the mucous membrane above the opening for the canula, and tightly closing the Fig. 246. — Section of trachea with packing of distal extremity. superior orifice by two mattress sutures of heavy chromic catgut. A No. 30 F rubber feeding tube is then introduced through the nostril into the esophagus and secured by a safety pin and plaster straps to the face. The wounds are next united above, with generous gauze packing about the tracheal canula (Fig. 247). Water is given through the tube as early as the morning following the operation if there is no nausea. Milk, coffee, egg-nog, meat juice, and soups follow as soon as possible. No attempt at swallowing should be made for at least seven days, after which the tube can be removed. The wound should 456 INJURIES AND DISEASES OF FACE AND NECK be dressed at least once every day, and two or three times if there is infection or pharyngeal leakage. The tracheal stump is quickly covered with granulations and gives no trouble. The patients continue with the silver canula. The after-treatment should be the same as that following tracheotomy. Patients should be encouraged to assume a sitting posture as soon as possible after operation. In the earliest stage of intrinsic cancer of the larynx, extensive dissection of the neck is not necessary, as the lymphatics are rarely involved. At a later period, however, and in all cases of extrinsic growth, a thorough removal of all nodes and lymph- bearing areolar tissue is imperative. Fig. 247. — Wound sutured, showing packing about trachea. Subhyoid Pharyngotomy. — Subhyoid pharyngotomy is occasionally useful for the removal of a small growth in the upper larynx. After a preliminary tracheotomy, transverse incision should be made just below the hyoid bone and the thyrohyoid membrane exposed. When all bleeding is arrested, this should be incised, the epiglottis drawn outward or excised, and the necessary procedures carried out, after which the wound should be closed with subcutaneous drainage. External Esophagotomy. — An incision is made along the anterior border of the left sternomastoid muscle from a point opposite the upper margin of the thyroid cartilage to the sternoclavicular articula- tion, dividing the skin, superficial fascia, and platysma. The omohyoid DISEASES OF THE EAR 457 muscle is retracted and the tissues separated by blunt dissection until the great vessels are reached. These are carefully retracted outward, the thyroid "land and overlying muscles retracted inward, and the lateral wall of the trachea and esophagus exposed. The recurrent laryngeal nerve should he found in the groove between these two structures and held aside. An esophageal bougie is next introduced from the mouth and the esophagus opened upon it as a guide. After the necessary procedures have been carried out, the esophageal wound should he closed with two layers of fine silk or chromicized catgut and the superficial structures united by layer suture. A rubber tissue or cigarette drain should be introduced whenever the wound has been contaminated. DISEASES OF THE EAR. Deformities. — The external ear may be notched, the pinna may lie absent, or the entire ear may project abnormally, giving rise to an unsightly appearance. These deformities may be corrected by plastic operations. Furuncles. — Furuncles occur with great frequency in the external auditory canal, and cause much annoyance by the pain, tenderness, and swelling of the parts. They occur usually in crops; as many as ten or twelve ma}' appear in an individual in as many weeks. They should be promptly incised and the ear frequently irrigated with carbolic acid solution (1 to 100). As in cases of furunculosis elsewhere, an effort should be made to increase the resistance of the individual by tonics, fresh air, exercise, and raising the opsonic index by the hypodermic injection of autogenous vaccines. Hematoma. — Hematoma of the external ear occurs in the insane and as a result of trauma. The lesion is a subperichondrial hemorrhage which frequently causes great thickening of the tissues and a deformity which never fully disappears. As a rule, no treatment is required. Occasionally when the bleeding occurs on the posterior aspect of the cartilage, incision and removal of the clots may be indicated if the case is seen sufficiently early. Otitis Media. — Otitis media is an acute inflammation of the mucous membrane lining the cavity of the tympanum, usually caused by an ascending infection through the Eustachian tube. Symptoms. — The symptoms are pain in the ear, deafness, fever, and a rapid, full pulse. The pain is severe and often of a lancinating character. On examination, the drum-membrane will be found reddened and bulged outward. This disease is of interest to the surgeon chiefly on account of its complications. If untreated, acute otitis media may be spontaneously relieved by rupture of the drum- membrane and evacuation of the pus. If considerable pressure exists from an accumulation of pus or septic fluid, the infection may spread to the mastoid antrum, giving rise to pain and tenderness behind 458 INJURIES AND DISEASES OF FACE AND NECK the ear, with redness and edema of the skin and subcutaneous tissues. If this condition is not promptly relieved by operation, the infection may extend to the neighboring mastoid cells, causing a more or less extensive osteomyelitis, which not infrequently involves the lateral sinus, causing septic thrombosis, pyemia, and death; or to the meninges or brain, giving rise to septic meningitis, cerebritis, or brain abscess. These latter complications are often the result of an acute exacerbation of an old subacute otitis media, the only symptom of which may be the presence of chronic otorrhea. Treatment. — The treatment of acute otitis media should be prompt incision of the drum and the relief of tension. The incision should be made in the lower posterior quadrant of the membrane, and should be followed by frequent irrigations with a warm solution of boric acid. Early incision, during the first few hours of the pain, when the cavity is filled simply with clear serum often will abort the process. The relief to the pain is immediate and the opening in the drum heals perfectly in a few days. Mastoiditis. — Although in general, cases of otitis media and mastoidi- tis are best referred to the specialist, the general surgeon not infre- quently is called upon for their treatment in acute septic conditions. Mastoid suppuration is practically always a sequel of otitis media and is characterized by pain and tenderness behind the ear extending often to the tip of the process. If the infection is acute, there will be redness and edema over the affected area with fever and leukocytosis. Treatment. — The treatment of mastoiditis should be prompt to avoid extension of the disease to the brain or lateral sinus. An incision should be made behind the ear from a point three-quarters of an inch above the meatus downward to the tip of the process. The incision is carried to the bone and the periosteum and soft parts retracted. An opening is then made by a small chisel or gouge into the mastoid antrum, which lies in the swprameatal triangle, a space bounded by the upper posterior margin of the bony canal, and two lines drawn tangent to the roof and posterior wall of the bony meatus. The antrum lies about three-fifths of an inch below the surface. In the early cases all that will be required is a free opening into the antrum, with disinfection and packing with gauze. If the disease has spread to the other cells of the mastoid process, it may be necessaty to expose and open them down to the tip of the process. The treatment of sinus thrombosis and of the cerebral complications of the disease has been considered in Chapter XIII. CHAPTER XVIII. INJURIES AND DISEASES OF THE THORAX, PLEURA, AND LUNG. INJURIES OF THE CHEST-WALL. Contusions. — Contusions of the chest-wall are of frequent occur- rence, and are only important on account of the complicating visceral injuries which may be associated with them. In the majority of instances severe contusions of the chest are accompanied by fracture of one or more ribs, the diagnosis and treat- ment of which will be considered in Chapter XXVII . Rupture of the parietal or visceral layer of the pleura, injury of the lung, and injuries of the pericardium and heart, may occur from severe blows or contusions of the chest without fracture or external wounds. Fatal shock has also been observed without apparent visceral injury. Injuries of the pleura are indicated by pain which is increased by deep inspiration, and by the presence of a friction-sound over the seat of injury. Rupture of the lung is indicated by cough, bloody expectoration, and the evidences of hemothorax and pneumothorax. Exceptionally no signs of visceral injury are apparent at the first examination. Subpleural injury of the lung may occur, and, in addition to the cough and bloody expectoration, may cause a subpleural emphysema which travels upward to the root of the lung through the mediastinal areolar tissue to the root of the neck, and from there may spread in any direction. In these cases pressure on the heart and great vessels frequently leads to disturbed heart action, marked dyspnea, congestion of the face, and dilatation of the superficial veins of the neck. The diaphragm is occasionally ruptured by a severe contusion or crush of the chest-wall, and, in some instances, a hernia of the stomach or other of the abdominal viscera may take place into the pleural cavity. Blows over the lower left chest often produce alarming symptoms of shock, which sometimes is fatal. Treatment. — The treatment of uncomplicated contusions of the chest calls for nothing other than rest and limiting the respiratory movements. This is accomplished best by a firm binder or adhesive plaster strips. If rupture of the lung is present, strapping the chest will limit the respiratory movements and give relief if the hemorrhage is not progressive. Absolute rest should be enjoined, and, if the symptoms of progressive hemorrhage are present, threatening life, 460 DISEASES OF THORAX, PLEURA, AND LUNG the chest should be opened and an effort made to find and secure the bleeding point. It not infrequently happens that a thoracotomy which allows air to enter the pleural cavity will cause the arrest of hemorrhage by collapse of the lung. Wounds of the Chest-wall. — Wounds of the chest-wall may be pene- trating or non-penetrating. The former are generally caused by severe compound fractures or by gunshot or stab wounds. If the wound is of sufficient size to admit air to the pleural cavity, pneumo- thorax results, which is indicated by cough, dyspnea, rapid respiration, the absence of respiratory sounds over the affected side, and the presence of an abnormal tympanitic resonance. Wounds in the lower half of the chest are not infrequently complicated by wounds of the diaphragm, and if sufficiently large a hernial protrusion into the thorax of the stomach or intestine may occur. In rare instances the injury may involve the thoracic duct, giving rise to chylothorax. In stab wounds of the chest with hemorrhage from a vessel of the chest-wall, the blood is often aspirated into the pleural cavity by the respiratory efforts, little or none escaping at the surface of the wound. In gunshot wounds of the thorax, those made by the modern small- caliber high-velocity weapons produce, as a rule, much less damage than those made b} the older large-caliber arms. In the former the track of the projectile is more often sterile, there is less splintering of bone, less laceration of lung tissue, and, consequently, less hemor- rhage and sepsis. Other things being equal perforating gunshot wounds of the chest are less serious than simple penetrating wounds, where the bullet remains in the pleural cavity or is imbedded in the lung. Injuries occurring near the root of the lung are more dangerous than those situated at a distance from the large vessels. It was observed in the Spanish-American and South African wars that many perforating wounds of the thorax made by Mauser bullets and other small-caliber, high-velocity projectiles, healed kindly and often without symptoms, the only dressing being the application of a sterile pad over the external wounds. If the lung is wounded, cough will be present and will be accompanied by bloody expectoration. If bleeding occurs into the pleural sac, either from a wound in the lung or from an injured vessel in the chest- wall, hemothorax will be produced, indicated by the presence of flatness over the lower part of the chest with absence of fremitus and of the normal respiratory sounds. If the bleeding is considerable, it may fill the greater part of the pleural sac and give rise to all the signs and symptoms of concealed hemorrhage. Subcutaneous emphysema is a frequent symptom of wounds of the chest. Non-penetrating wounds of the chest-wall present no special features. Lenormant has recently expressed the opinion that in these cases of extensive hemothorax, death more often results from pressure on the heart and mediastinal structures, than from the actual loss of blood. INJURIES OF THE CHEST-WALL 461 Treatment. — In regard to the treatment of penetrating wounds of the thorax, surgical opinion is divided. Many surgeons of large experience as Zeidler and Lavroff, advise operation in all cases, for the reason that the extent of the injury cannot be determined by the early symptoms and signs. Other authorities, of equal experience, including Lucas-Championniere, Lenormant and Holmberg, advise conservative treatment in the absence of symptoms and signs of alarming or progressive hemorrhage, greatly embarrassed respiration, gross septic contamination of the pleura, or a probability of injury to the heart, mediastinal structures or diaphragm. In the treatment of these injuries it must be remembered that there is a strong prob- ability of cardiac injury if the wound occurs in the "heart zone" described by Zeidler,* as the space limited above by the second rib, externally by a line from the junction of this rib with the anterior axillary line to the seventh intercostal space on the nipple line. Also that all penetrating wounds below the fourth intercostal space may injure the diaphragm. In injuries of the diaphragm, thoracotomy is necessary, and the wound should be repaired by drawing the edges together with chromic catgut sutures. In injuries of the esophagus a larger thoracotomy wound will be necessary, with ample retraction of the collapsed lung, to insure accurate suture. In all of these operations, positive pressure anesthesia by the intratracheal method of Meltzer and Auer should be employed: skilled assistants and a good light are essential; the question of drainage must be determined by the probable amount of contamination of the pleura. Where there is reason to believe that the pleural cavity has not been grossly infected, and there are no signs of alarming hemorrhage, or of injury to the heart or diaphragm, the external wound should be carefully disinfected and sealed with a sterile dressing. Embarrassed respira- tion occurring later as a result of pneumothorax or the presence of blood or a serous exudate, often may be relieved by aspiration. If empyema develops, drainage should be established. Probing the wound is dangerous, and, as a rule, furnishes no valuable information. Air in the pleural cavity is quickly absorbed if the wound of entrance is sealed. Free blood in the pleural cavity quickly clots, and if sterile absorbs readily. The presence of blood and air from an external wound in the pleural cavity usually results in infection and empyema. Blood in the pleural cavity with air from a wound in the lung without external contamination generally remains sterile, and eventually is absorbed. If there is reason to believe that a penetrating wound of the chest is infected, it should be explored, enlarged if necessary, and the pleural cavity drained with gauze or rubber tube. In the presence of a progressively increasing hemothorax, the wound into the pleural cavity should be enlarged by the removal of one or more rib segments, the clots removed, the sources of the 462 DISEASES OF THORAX, PLEURA, AND LUNG hemorrhage located and treated if possible by ligation or the suture-ligature. If this is impossible, gauze packing may be em- ployed with pressure at or near the bleeding point. DISEASES OF THE CHEST-WALL. Abscess. — Abscesses of the chest-wall differ in no way from abscesses in other parts of the body, excepting those which occur under the pectoral muscle and those which occur in the axilla. Fig. 248. — Chronic suppurative pleurisy; chronic osteomyelitis of the ribs. Subpectoral Abscess.- — Subpectoral abscess results from a cellulitis beneath the pectoral muscles, which may arise from a neighboring wound, from lymphatic infection, from disease of the bone, or as a part of some general septic disease. The symptoms may be misleading at first, but localized pain is generally present, and is greatly increased on attempting to raise the arm above the head. Fluctuation is often obscured by the overlying muscle. The treatment should be by free incisions and drainage. PLATE XVI Tuberculosis 01 Costal Cartilages. (Lumiere Photograph.) TUMORS OF THE CHEST-WALL 463 Axillary Abscess. — Axillary abscess is generally the result of infection of the axillary lymph nodes. The suppuration may be extensive and burrow deeply in the axilla around the great vessels and nerve- trunks. The treatment should consist in freely opening the axilla, with removal of the pus and diseased glands. This can only be accomplished by a generous incision, a good light, and ample retraction of the wound edges. The knife should be sparingly used, and after the first incision is made removal of the diseased glands may be accom- plished largely by the finger or blunt dissection. Osteomyelitis of the Ribs. — Osteomyelitis of the ribs or sternum may occur and give rise to abscesses with more or less extensive necrosis of the bones. Acute septic osteomyelitis is rarer than the typhoid, syphilitic, or tuberculous variety. It is apt to occur in the rib near the chondral junction. The process at first involves the medullary cavity, finally erodes the cortex, and produces a subperiosteal abscess, which in turn may rupture on the surface or, rarely, within the pleura. In typhoid osteomyelitis the process is subacute, as a rule, and the bone focus much more limited in extent. In the tuber- culous variety the entire course of the disease may be painless, the first indication being the presence of an oblong, fluctuating swelling- over the rib without heat or redness. In the acute septic variety there is, as a rule, severe boring pain, with edema and redness of the overlying soft parts, fever, and evidences of toxemia. Treatment. — In the treatment of the septic variety of osteomyelitis of the ribs or sternum early incision through, the periosteum will often give marked relief and limit, to a considerable extent, the destruc- tion of bone. In all, thorough removal of the bone focus is essential, followed in the tuberculous cases by curetting and packing with iodoform or formalin gauze. TUMORS OF THE CHEST-WALL. Tumors of the chest-wall are conveniently divided into those arising from the soft parts and those taking their origin from the bony framework. Of the former may be mentioned fibroma and fibroma molluscum, lipoma, sarcoma; sebaceous, dermoid, or echino- coccus cysts; of the latter, osteoma, chondroma, and sarcoma are the most important. The tumors of the soft parts differ in no respect from similar tumors developing in other parts of the body which have already been sufficiently considered. Osteomata are most frequently found growing from the ribs at or near their junction with the costal cartilages. In the majority of instances they represent ossified chondromata. They give rise to no symptoms, and are of surgical interest only when the deformity renders removal necessary. 464 DISEASES OF THORAX, PLEURA, AND LUNG Chondromata are found less frequently in the sternum than in the ribs, and in either situation are generally near a joint. They so frequently degenerate into sarcoma that Quenu and Longuet advise the same radical removal as for sarcoma. Sarcoma is, undoubtedly, the most frequently observed tumor of the bony thorax. It occurs as a central or periosteal pure growth or as a mixed tumor (osteo- chondro- or myxosarcoma). A rare and exceedingly soft pulsating endothelioma of bone is occasionally observed in this locality. Prognosis. — The prognosis in sarcoma of the thoracic wall is exceed- ingly grave, as only the most thorough removal at an early date will give hope of a radical cure. Treatment. — In chondroma of the ribs or sternum wide excision is to be advised in the early stage. In sarcoma and in recurrent or advanced chondroma of the ribs, complete resection of the chest- wall is the operation of choice, for the reason that the involvement of the pleura takes place at an early period. In sarcoma of the sternum extensive operation is demanded, but is a formidable procedure on account of the danger of wounding important mediastinal structures. DISEASES OF THE PLEURA. Pneumothorax. — This is a condition characterized by the presence of air in the pleural cavity. It may arise from an external wound, from traumatic rupture of the lung, from rupture of a tuberculous cavity, or, rarely, from infection by a gas-producing micro-organism. The effect of a pneumothorax unassociated with an external wound (closed pneumothorax) is only a moderate interference with respiration noticed on unusual exertion. Where there is an open pleural wound (open pneumothorax) the dyspnea is more marked, due not only to collapse of the affected lung, but to the absence of the piston action of the diaphragm. Len- ormant has recently described a particularly dangerous type of pneu- mothorax which he designates pneumothorax a soupape, or valvular pneumothorax; in which by the condition of the external wound, air is aspirated into the pleura by each inspiratory act, but none escapes. This quickly results in great intrapleural pressure, dislocation of the heart and other mediastinal structures, giving rise to grave and increasing dyspnea. Symptoms. — The symptoms of open pneumothorax are dyspnea and cyanosis on exertion, cough, rapid heart action, and extreme discomfort. If the opposite lung is diseased, all of these symptoms are exaggerated. Double pneumothorax is generally fatal. Treatment. — In spontaneous pneumothorax from the rupture of a tuberculous cavity no operative treatment is required, as the gradual collapse of the lung, from the accumulated air and the associated DISEASES OF THE PLEURA 465 serous effusion, favors closure of the pulmonary opening. At a later period the fluid gradually may be removed by aspiration. Jn open pneumothorax, if uninfected, closure of the thoracic wound generally gives prompt relief by restoring the piston action of the diaphragm. In pneumothorax a soupape aspiration should be tried, and if the symptoms recur, the valvular opening should be enlarged, a drainage tube inserted, and later one of the methods of aspiration drainage employed. If the pleura is infected, drainage must be instituted. Removal of the air by aspiration from a closed pneumothorax with disease of the other lung, will often give a large measure of relief. Hydrothorax. — Hydrothorax is an effusion of serum into the pleural sac. This affection is caused by pleuritis or pneumonia, by wounds of the pleura or lung, by foreign bodies, new growths, or by tuberculo- sis. It occurs also as a bilateral affection in chronic renal or cardiac disease and in general sepsis. Symptoms. — The symptoms are a gradually increasing shortness of breath on exertion and cough. The signs are a diminished area of resonance and respiratory murmur, flatness, absence of fremitus, and egophony. Treatment. — The treatment should consist in the administration of cathartics and diuretics. Removal of the fluid by aspiration is to be recommended if absorption is slow or fails to occur. Chylothorax. — The presence of chyle in the pleural cavity is due to rupture of the thoracic duct, generally the result of a fracture of the spine or crush of the chest. The diagnosis is made by an exploring needle. Repeated aspirations have in some cases resulted in a cure of the condition. Pyothorax (Empyema). — Pyothorax or empyema, is a collection of pus in the pleural sac. This occurs as a result of infection of a pre- existing pleuritic effusion, or may arise immediately as a result of a penetrating wound of the thorax, from extension from a neighboring septic focus as a pneumonia, an abscess of the lung, chest-wall, liver, or subphrenic region. It may arise also from lymphatic extension from an abdominal focus. In certain cases the process is distinctly localized and is shut off from the general pleural cavity by adhesions. In other rare instances such a collection of pus may be situated between the lobes. This variety cannot be differentiated from abscess in the lung-tissue. In the great majority of cases empyema follows pneu- monia. When due to the pneumococcus the pus is thick and creamy in appearance and the prognosis is favorable. When due to grip infection, to the streptococcus, staphylococcus, or colon bacillus, the pus is thin and watery, frequently contains flakes of fibrin, and may have a foul odor. In these cases the prognosis is more grave. In the tuberculous variety the pus is whitish, thin, and contains 30 466 DISEASES OF THORAX, PLEURA, AND LUNG masses of caseous material. In all cases the parietal and visceral pleura are thickened and covered with a fibrinous exudate. Symptoms. — The symptoms of a non-tuberculous empyema often are obscure in the early stages, and the case not infrequently is regarded as one of delayed resolution of a pneumonia. Sooner or later, however, there will be more or less dyspnea, cough, fever, chills, sweats, a high leukocytosis, and evidences of grave toxemia. In the tuberculous cases the onset is still more insidious. While cough and dyspnea may be present, fever, chills, leukocytosis and acute toxemia are absent. The signs arc those of fluid in the chest, with displacement of the heart and other mediastinal viscera. In many cases a positive diagnosis can only be made by an aspirating syringe. Fig. 249. — Wilson's empyema drainage tube. Treatment. — In all cases of non-tuberculous empyema the treatment should consist, in early evacuation of the pus and the establishment of adequate drainage. Thoracotomy with the resection of one or more ribs and the introduction of a double rubber drainage tube or better still a Wilson double-flanged drainage tube (Figs. 249 and 250) constitutes the best routine treatment. In adults the operation can be performed with cocaine. In children, as a rule, it is better to give a small amount of ether. During the past few years many surgeons have adopted means to insure continuous suction drainage in cases of empyema. This when successful promotes a rapid removal of the pus, and insures a prompt expansion of the compressed lung and shortens to considerable extent the duration of after-treatment. The simplest of these is by means of a Pollitzer bag attached to the drain- age tube, as recommended by Bryant (Fig. 251), or by hydrostatic DISEASES OF THE PLEURA 467 Fig. 250. — Wilson's empyema drainage tube in position. (Brewer, in Keen's Surgery.) Fig 251. — Bryant's empyema drainage. 468 DISEASES OF THORAX, PLEURA, AND LUNG pressure by means of two Wolff bottles. To insure success in any method of suction drainage, the tube entering the chest must be made Fig. 252. — Continuous suction drainage by siphonage. Fig. 253. — Brewer's empyema drainage tube. (Keen.) DISEASES OF THE PLEURA 469 air-tight. This is best accomplished by the employment of the author's double-flanged tube secured by adhesive plaster (Figs. 253 and 254). In old neglected empyemas, where the lung will not expand to fill the pleural cavity, one of several methods may be employed: First, the use of the pneumatic cabinet to forcibly expand the lung: Fig. 254. — Brewer's empyema drainage tube in place, held by adhesive plaster. (Keen.) second, removal of the fibrinous envelope which encloses the lung and prevents expansion, third, plastic operation on the chest-wall to enable it to collapse on the contracted lung and fourth, the injection into the cavity of bismuth paste (1 part of arsenic-free subnitrate of bismuth, and 2 parts of sterile vaseline). Several injections should 470 DISEASES OF THORAX, PLEURA, AND LUNG be made at intervals of from two to seven days. This method, advised by Beck, of Chicago, should be tried in all cases before resorting to the graver thoracoplasties. The treatment of tuberculous empyema is to avoid open operation until the pus points on the chest-wall, and by hygiene, fresh air, good food, and tonics to improve the normal resistance of the patient. In certain rare cases where dyspnea constitutes an urgent symptom, aspiration of the pus is to be advised. The treatment of the interlobar empyema is the same as for abscess of the lung. DISEASES OF THE LUNG. Abscess of the Lung. — This condition is comparatively rare. It occurs as a sequel of lobar pneumonia, in which case the abscess is generally single; as a result of septic bronchopneumonia, in which case the abscesses may be numerous and scattered throughout both lungs; as a result of tuberculosis, foreign body, bronchiectasis, or pyemia. It has recently been shown that the pneumonias due to influenza are more frequently complicated with abscess of the lung than the ordinary variety. Symptoms. — The symptoms of abscess of the lung are often obscure. If, following a lobar pneumonia, resolution is delayed and the pulse and temperature remain high, chills, sweats, and progressive asthenia develop, abscess is to be suspected. The signs are those of a limited area of consolidation. According to Tuffier's statistics, abscess of the lung is found more frequently in the lower than the upper lobe, and, as a rule, nearer the posterior surface. As the physical signs frequently are misleading, a positive diagnosis is often delayed until the patient is prostrated by prolonged toxemia. In the writer's experience the ,r-rays are often of great service in locating a focus. Exploratory aspiration often is necessary to establish the diagnosis. When the abscess has ruptured into a bronchus, the presence of an exceedingly pungent, foul-smelling expectoration is characteristic. In these cases a prolonged paroxysm of coughing is apt to occur in the morning, which empties the cavity. Treatment. — The treatment of abscess of the lung is by incision and drainage. An incision is made over a rib, the soft parts retracted, and the intercostal muscle divided, exposing the parietal layer of the pleura. If an adhesion exists between the parietal pleura and lung, the former will appear opaque; if no adhesion is present, the pleura will be translucent and the mottled lung will be seen to move beneath it (Keen). If adhesions are present, a director may be gently intro- duced into the lung, and when pus is reached the opening may be enlarged by passing a closed pair of dressing-forceps along the groove of the director and withdrawing them partly opened. The finger may then be passed into the wound and the cavity explored. A drainage tube should be introduced and supported by gauze packing. DISEASES OF THE LUNG 471 A heavy gauze and cotton dressing should be applied and the wound dressed as infrequently as possible. If there is no adhesion between the layers of the pleura and the symptoms are not urgent, packing the wound for forty-eight hours will result in adhesions forming, leaving a space through which the abscess subsequently may be opened as above. If the symptoms do not warrant such delay, the pus should be evacuated at once and provision made for drainage of the pleural cavity, which is sure to become infected. In cases where the abscess ruptures into a bronchus without relief of symptoms, the question of external drainage should be considered. In these cases, which often pursue an exceedingly chronic course, Murphy believes the cause of delayed resolution to be the presence of adhesions which prevent collapse of the lung and its contained cavity. For this he advises thoracotomy, the intro- duction of the hand into the pleural cavity, separation of the adhesions, allowing collapse of the lung. A less hazardous operation in these cases would be extrapleural thoracoplasty or removal of a sufficient number of ribs without opening the pleura, to allow the chest-wall to collapse, causing shrinkage of the lung and closure of the abscess cavity. Where no adhesions exist the production of an artificial pneumothorax by the introduction of sterile nitrogen gas into the pleural cavity is to be recommended. Prognosis. — The prognosis in abscess of the lung is always grave. Single abscesses treated in the manner just described frequently recover. In cases of multiple abscesses of metastatic origin surgical procedures are contra-indicated. Bronchiectasis. — Dilatation of the bronchi is of frequent occurrence in patients suffering from chronic cough. In the majority of instances the dilatations are fusiform, multiple, and associated with an abundant putrid secretion. These cases are not to be subjected to surgical treatment. In certain rare instances there exists a sacculated dila- tation which communicates with the bronchus by a narrow opening. These cases strongly resemble chronic abscess of the lung, and often may be relieved by surgical treatment. Symptoms. — The symptoms of a sacculated bronchiectasis are: morning cough, with expectoration of a large amount of extremely fetid pus, followed by a period of rest until the cavity refills. Y\ ith this there is a loss of appetite and strength, a foul breath, more or less emaciation, and evidences of slowly progressing sepsis. The physical signs are those of a cavity when the sac is empty, of an area of consolidation when full. The .r-rays are often of value in locating the focus. Treatment. — The treatment should be the same as for abscess of the lung which has ruptured, collapse of the lung by the introduction of sterile nitrogen gas in the pleural cavity where no adhesions exist, extrapleural thoracoplasty where adhesions are present of sufficient extent to prevent collapse of the lung. In certain obstinate cases some 472 DISEASES OF THORAX, PLEURA, AND LUNG authorities advise freely opening the pleural cavity, accurately locating the lesion by palpation, separating all adhesions, and draining both pulmonary focus and the pleural cavity. Gangrene of the Lung. — Pulmonary gangrene may arise from the same causes as abscess of the lung. It occurs generally in greatly debilitated subjects, and is often associated with diabetes, nephritis, alcoholism, and starvation. In the majority of cases it follows pneu- monia. In rare instances it may be the result of pulmonary embolism. Symptoms. — The symptoms of gangrene of the lung are an exceed- ingly foul odor to the breath, followed by the expectoration of a large amount of dark-colored material, which, if allowed to stand in a glass, will appear frothy on top and contain at the bottom of the glass shreds and masses of gangrenous tissue. Added to this, there is extreme prostration, often with a subnormal temperature and a rapid, thready pulse. In other cases the temperature may be elevated. Hemorrhages may occur, and in some instances be the immediate cause of death. Prognosis. — The prognosis in gangrene of the lung is exceedingly grave. Prior to the employment of surgical measures the mortality was upward of 80 per cent. In cases treated surgically the death rate is between 30 and 40 per cent. Treatment. — The treatment should consist in freely opening the pleural cavity, locating the area of necrosis, and establishing drainage by generous gauze-packing until the slough separates spontaneously, after which it should be removed and free drainage maintained for the infected pleural cavity. Actinomycosis of the Lung. — While the primary lesions of actino- mycosis occur most frequently in the digestive tract, occasionally they are seen in the lungs as a result of aspiration of the ray fungus. Secondary pulmonary lesions, however, are far more frequent, and are the result of an extension of the disease from some abdominal focus. The disease in the lung gives rise to areas of consolidation re- sembling tuberculosis. Later these break down, forming cavities with an excessive formation of granulation tissue. The pleura and chest-wall are finally invaded with the formation of large areas of brawny induration of the skin and sinuses. As a result of adhesions and contraction of the abundant granulation tissue, retraction of the chest-wall takes place, often with marked deformity. Symptoms. — The symptoms of pulmonary actinomycosis develop slowly. There are pain, cough, moderate fever, and loss of weight and strength. The physical signs at first are similar to those of tuber- culosis. The diagnosis can only be established by observing the small yellow masses in the discharges, which upon microscopic examination reveal the ray fungus. Treatment. — The treatment should consist in opening and draining pus cavities and the administration of potassium iodide or the copper salts. If the diagnosis of a small primary focus could be established DISEASES OF THE LUNG 473 early radical removal by pneumectomy would be the rational treat- ment. Tuberculosis of the Lung. — The surgical treatment of tuberculosis of the lung has recently been revived, and is receiving serious attention. The idea of completely removing a small isolated focus by resection of a portion of the lung tissue is no longer advocated by surgeons, for the reason that the mortality of such a procedure is high, and the results no better than those which can be obtained by the open-air treatment in incipient cases. The idea of causing a collapse of the lung which is the seat of a tuberculous lesion seems to be more rational. Some time ago Murphy reported a series of cases in which considerable benefit was obtained by producing an artificial pneumothorax by the introduction of sterile nitrogen gas into the pleural cavity, and recently Forlanini, Brauer and others have reported numerous successful cases by this method. When dense adhesions are present which would interfere with the complete collapse of the lung by the nitrogen injection, Garre, Quincke, and others have advised the removal of several ribs over a tuberculous focus to allow collapse of the soft tissues, and to promote thereby a shrinkage in the volume of the lung and obliteration of the cavity. Tuffier has recently advised and successfully practised removal of one or more ribs, stripping the parietal pleura from the chest wall over a large area, and filling the dead space thus produced with masses of fat. Many of these operations have been followed by encouraging results. Friedrich, of Marburg, has recently advised far more extensive resections, allowing complete collapse of the lung on one side. His operation consists in raising an enormous musculocutaneous flap from below upward, exposing the ribs from the second to the tenth. These are next resected from their cartilage to the spine, the posterior layer of periosteum being left adherent to the intact pleura. This procedure results in the immediate complete collapse of the lung. The large flap is then replaced and sutured, and an aseptic dressing applied. While this formidable operation would seem almost too hazardous in the advanced cases in which he considers it indicated, he reports that 70 per cent, of the unilateral cases survive the operation and show marked improvement in symptoms. While sufficient data are not yet available to enable one to form an opinion regarding the usefulness of these procedures, the principle that collapse of a tuberculous lung favors resolution seems to have been established. Pulmonary Emphysema. — Freund, of Berlin, has recently called attention to the fact that in certain cases of alveolar emphysema the symptoms are due to an abnormal ridigity of the chest -wall. This rigidity he believes to be caused by calcification and other pathologic changes in the costal cartilages resulting in a diminution in their 474 DISEASES OF THORAX, PLEURA, AND LUNG normal elasticity. These changes have been noted more particularly in the second and third cartilages on the right side, but they may be present in any or all of these structures. Acting upon the suggestion furnished by these observations, Hilde- brand, Haasler, and other German surgeons have resected two or more costal cartilages on one or both sides. This allowed a greater excursion of the corresponding ribs during the respiratory movements and gave considerable relief to the dyspnea. Goodman has recently reported four cases treated at the Monte- fiore Home by this method with encouraging results. While the opera- tion cannot be expected to cure the lung lesion, it is reasonable to suppose that considerable relief may be expected in suitable cases. To insure the best results the perichondrium should be completely removed, as several cases of recurrence have been reported where this precaution has been neglected. Gummatous Infiltration of the Lung. — Gummatous infiltration of the lung occurs as a late lesion of syphilis. The symptoms are by no means characteristic. The gummata may break down and form cavities similar to those due to tuberculosis, the difference being that the former are often greatly improved by antisyphilitic treatment. NEW GROWTHS OF THE PLEURA AND LUNG. Tumors arising from the pleura are rare. The one most frequently observed is endothelioma, which grows slowly, and often without symptoms until it gives rise to dyspnea by encroaching on the lung space. Occasionally it causes a pleural exudate. Sarcotna, which is rare, grows rapidly, and is generally associated with a bloody serous exudate. The physical signs of these growths are those of fluid in the chest; flatness, absence of respiratory sounds, and fremitus. In sarcoma, Warthin states that atypic cells with mitotic figures sometimes can be demonstrated in the fluid. Primary carcinoma and sarcoma may occur in the lung, the former being most frequently encountered. The symptoms of a primary malignant tumor of the lung are: an afebrile cough, with an area of rapidly advancing consolidation, followed later by dyspnea, bloody expectoration, a hemorrhagic pleural exudate, and a rapidly advancing cachexia. The occurrence of these symptoms in an individual who has already a carcinomatous or sarcomatous focus elsewhere in the body is sufficient to justify the diagnosis of a secondary malignant process in the lung. Seydel, who recently published an interesting analysis of lung tumors from the autopsy records of the Munich Institute, states that of the primary sarcomata and carcinomata 73 per cent, of the former and 90 per cent, of the latter were clearly inoperable. No case of solid benign tumor of the lung was found in the 10,829 autopsy reports analyzed. DISEASES OF THE MEDIASTINUM 475 Treatment.— It early diagnosis of a primary malignant tumor of the lung can be made, pneumectomy is indicated. Echinococcus Cysts.— Echinococcus cysts occur more frequently in the lung than in any other organ of the body except the liver. The disease, however, is rare in the United States, most of the cases occur- ring in immigrants or those who have visited foreign countries. Symptoms. The symptoms of echinococcus disease of the lung are mainly those of pressure, dyspnea, displacement of the heart, and other mediastinal structures, cough, bulging of the chest, and a dislocation downward of the liver. The signs are those of an intra- thoracic tumor. In the diagnosis of this condition, marked eosino- philia, the reaction of fixation of complement, the physical signs of an intrathoracic tumor and the x-rays are the most important factors. The .r-ray shadow should be round, with well-defined borders, and without evidences of an infiltrating lesion. Prognosis. — The prognosis in this condition is grave if untreated, as rupture may take place into a bronchus and cause asphyxia, or the fluid may become infected and cause a fatal toxemia. Treatment. — The treatment should consist in marsupialization or stitching the cyst-wall to the external wound for continuous drain- age. Occasionally it may be possible to remove the inner or secreting layer of the sac. DISEASES OF THE MEDIASTINUM. Injuries of the mediastinal structures are rare, except in fractures of the spine or crushes of the chest-wall. When the heart and great vessels are injured death results so rapidly that little or nothing can be done. Hemorrhage into the mediastinal space, when not due to injury of the large vessels, is seldom serious, and if uninfected is quickly absorbed. Gunshot wounds may injure the trachea, bronchi, or esophagus, giving rise to emphysema or septic inflammation. Medias- tinal emphysema extends rapidly to the root of the neck and from there spreads in any direction. It may give rise to grave dyspnea from pressure on the heart and great vessels. The condition sometimes can be relieved by making an incision into the cellular plane just above the suprasternal notch and applying a Bier cup. Acute Mediastinal Cellulitis. — Acute mediastinal cellulitis may arise as a result of trauma, osteomyelitis of the spine or sternum, infection by the lymphatics, or by an extension downward of a cellulitis of the neck. It is most frequently located in the upper and anterior portion of the space, 30 out of 36 cases reported by Hare being located in that region. Symptoms. — The symptoms are deep-seated pain and tenderness over the sternum, fever, leukocytosis, and evidences of grave toxemia. Later, the pus may point at the root of the neck, by the side of the ensiform or between the costal cartilages. 476 DISEASES OF THORAX, PLEURA, AXD LUNG Treatment. — The treatment at first should be by local applications of cold and measures to increase the normal resistance. If signs of suppuration appear, the sternum should be trephined and an effort made to locate and evacuate the pus. NEW GROWTHS OF THE MEDIASTINUM. Both benign and malignant tumors may occur in the mediastinum. The latter are more frequent, the proportion being four to one. Of the benign growths may be mentioned lipomata, fibromata, dermoid and echinococcus cysts. Of the malignant, sarcoma and carcinoma. Fig. 255. — Dilated veins of head and neck from mediastinal tumor. With the exception of the cysts, benign tumors rarely give rise to symptoms requiring surgical interference. Primary carcinoma may develop from the remains of the thymus gland. Primary sarcoma occurs most frequently in the lymph nodes and is exceedingly malignant. Lymph-node tumors of Hodgkin's disease are rare. Secondary malignant growths are not infrequent. Symptoms.— The symptoms of a mediastinal tumor are pain, cyanosis, and dilatation of the veins of the face and neck, dyspnea, and in some cases a unilateral or bilateral edema of the chest-wall OPERATIONS UPON THE THORAX 477 from azygos pressure (Fig. 2.").")). The .r-rays may reveal shadows which will aid the diagnosis. Treatment. — The treatment should at first be an exploratory trephine opening through the sternum, which later can be cautiously enlarged with a view to exposing the growth. Extirpation of accessible tumors, enucleation or drainage of cysts, or simply the removal of pressure by a wide resection of the bone would constitute the most rational treatment. In inoperable malignant growths the .r-rays may cause a diminution in the pressure symp- toms and in some instances an actual diminution of the size of the tumor has been observed. OPERATIONS UPON THE THORAX. Paracentesis. — This operation is indicated for the removal of an effusion, fluid blood, or air from the pleural cavity. It consists in the introduction of an aspirating needle through the chest-wall at a point where the physical signs indicate the presence of fluid. When the fluid is not encapsulated, but free in the pleural sac, the site selected is usually in the postaxillary line through the eighth or ninth intercostal space. The region is prepared in the usual manner, and a sterile needle thrust through the chest just above the upper border of a rib to avoid wounding the intercostal vessels. Xo anesthetic, as a rule, is required. "When the needle is felt to be within the pleural cavity the aspirating tube is attached and the fluid with- drawn. The small wound is afterward sealed with collodion or covered with a strip of sterile adhesive plaster. The Establishment of an Artificial Pneumothorax. — This procedure is indicated when for any reason it is desirable to produce a contraction of the lung. A sterile trocar is introduced through the soft tissues down to a rib. The needle is then withdrawn and the canula connected with a reservoir of sterile nitrogen gas by means of a rubber tube. The canula is then pushed upward above the rib and thrust into the pleural cavity. When this is reached the gas will flow into the pleura and gradually compress the lung. From 500 to 2000 c.crn. of the gas may be introduced. A pneumothorax thus created will often last for from three to five months. Thoracotomy. — Thoracotomy, or creating an opening through the chest-wall with a view to draining the pleural cavity, may be accom- plished by an incision between the ribs, or a portion of one or more ribs may be resected. The latter plan is the one generally adopted when the object is to evacuate and permanently drain an empyema. In an encysted empyema the opening should be established over the lowest part of the collection; in an ordinary empyema the incision should be between the seventh and tenth ribs, depending 478 DISEASES OF THORAX, PLEURA, AND LUNG upon the amount of fluid and the position of the diaphragm. A point should be selected just posterior to the anterior axillary line, and an incision made midway between two ribs, dividing the tissues down to the pleura, which may be opened with a knife or by puncture with a director and subsequent dilatation. If a portion of a rib is to be resected, the incision should be made directly over the bone and ^v V ^F P ^\ v^tS|jS|^, Hl^? ^Sff^W- Wm. '•^% vfl 3r j ;rir / e3S2e«I Fig. 256. — Resection of ribs for empyema. (Brewer, Keen's Surgery.) carried through the periosteum. The soft parts are to be scraped from the bone by a raspatory or periosteum elevator, care being taken to keep close to the bone in order to remove the periosteum completely from its posterior and inferior aspects. This prevents wounding the intercostal vessels. When the bone is cleared, it is cut by bone-forceps or a Gigli saw, and a piece from one to three inches in length removed OPERATIONS UPON THE THORAX 479 (Fig. 256). After all hemorrhage is arrested the opening into the pleural sac may be made as above described and the pus evacuated. Two drainage tubes tied together should then be introduced, or the double-flanged rubber drainage tube suggested by Wilson. If ordinary tubes are used, they should be introduced only far enough to insure drainage, as long tubes passed into the costodiapbragmatic sinus are a source of irritation, and not infrequently cause deep, slowly healing sinuses. The pleural cavity should not be irrigated except to effect removal of large masses of fibrin. A large absorbent dressing should be applied and the dressings changed only when saturated with the discharge. In the majority of instances this operation is performed best under general anesthesia. . Local anesthesia should be employed if the respiration is seriously embarrassed or the condition of the patient does not permit the use of ether or chloroform. When a more extensive exposure of the thoracic cavity is required, as for decortication of the lung, pneumectomy, or operations on the thoracic portion of the esophagus, complete removal of one or more ribs with wide retraction of the wound affords ample room for all ordinary procedures. Thoracoplasty. — Thoracoplasty consists in a resection of several ribs to enable the rigid chest-wall to collapse upon a contracted lung, and thus to obliterate a suppurating dead space. It is indicated in old empyemas which will not heal, and has recently been recommended to allow contraction of the lung for the purpose of obliterating tuber- culous or other chronic cavities in which openings into a bronchus have been established. Estlander's operation for chronic empyema consists in the removal of portions of several ribs, according to the size and shape of the underlying cavity, but without disturbing the thickened parietal pleura. This may be accomplished by raising a large flap of skin and muscle, thereby exposing four or five ribs from their angles to their attachments to the costal cartilage. The ribs are then resected as described above and the relaxed chest-wall pressed firmly down upon the lung. The original opening into the pleural sac should be enlarged, the cavity curetted, injected with hydrogen peroxide, and irrigated with sterile salt solution. Schede's operation consists in removing not only the ribs, but also the thickened parietal pleura. He advises a large U-shaped incision beginning near the junction of the second rib and costal cartilage, extending downward and backward to the tenth rib, then upward to the upper posterior angle of the scapula. The skin and superficial muscles are separated from the chest-wall and drawn upward, carrying the scapula with them. The ribs, from the second to the lowest limit of the pleural sac, are then removed with heavy bone-forceps and scissors, and with them the intercostal muscles and thickened pleura. The large skin and muscle flap is then replaced, sutured, and pressed 480 DISEASES OF THORAX, PLEURA, AND LUNG firmly against the collapsed lung. The operation is a dangerous one, and should not be attempted unless the surgeon is provided with an adequate number of competent assistants and every facility for meeting and controlling severe hemorrhage and profound shock. Friedrich's operation for the cure of pulmonary tuberculosis is the same as Schede's, except that the resection of the ribs is a sub- periosteal resection, the pleural cavity not being opened. Osteoplastic Resection of the Chest-wall. — This operation is under- taken for exploratory purposes, operations on the heart and peri- Fiu. 257. — Osteoplastic thoracotomy. (Brewer, Keen's Surgery.) cardium, for the removaljof tumors of the lung and pleura, for the removal of foreign bodies in the bronchi and esophagus, and for the treatment of empyema by the Fowler method. An incision is made parallel with the median line of the body, about one inch from the sternum, exposing the costal cartilages of four or five ribs. From either extremity of this incision two others are made outward over the intercostal spaces. The costal cartilages are divided with bone-forceps, the intercostal vessels doubly ligated and cut, the incisions carried through the entire chest-wall, and the rectangular flap raised and bent outward, breaking the ribs at the OPERATIONS UPON THE THORAX IS] Junction of the flap with the healthy chest-wall (Fig. 257). When the necessary intrathoracic procedures have been carried out the flap is returned and sutured in place with or without drainage. A similar Hap may be made in any part of the chest. Decortication of the lung, or Fowler's operation for empyema, con- sists in exposing the retracted lung through an osteoplastic opening in the chest, incising the thickened layer of visceral pleura, stripping it from the surface of the lung, and removing it with scissors. In children this often results in immediate expansion of the lung, often to a degree which nearly fills the pleural cavity. In adults it is rarely as satisfactory. It should be advised at an early period before inter- stitial changes have occurred in the lung to prevent its expansion. Pneumectomy. — This operation, which consists in removal of a portion of the lung, is occasionally undertaken in extensive wounds or laceration of the organ, for the removal of malignant growths, or, rarely, in tuberculosis or gangrene. The chest is opened by the osteoplastic method or by complete resection of one or more ribs. The affected portion of the lung is next delivered through the wound, transfixed and securely ligated, after which the diseased area is removed. Nathan Green surrounds the lung above the portion to be removed by a subpleural ligature of silk or heavy chromic catgut, and after the distal portion has been excised, sutures the pleural edges together by a continuous suture of plain catgut. After either procedure the stump is replaced within the pleural cavity and the thorax wound closed with or without drainage. Anterior Mediastinal Thoracotomy. — The structures in the anterior mediastinum can be exposed by the operation of Milton, which consists in a median longitudinal section of the sternum, with separation of the two halves. Another method is to make an osteoplastic resection of a rectangular portion of the sternum, dividing the cartilages along one side, sawing transversely through the sternum above and below, and turning the flap to the opposite side, breaking the cartilages beneath the cutaneous pedicle. In these operations the greatest care should be exercised to avoid wounding the pleura, the internal mam- mary artery, or the great vessels issuing from the base of the heart. Posterior Mediastinal Thoracotomy. — By this operation access to the posterior mediastinum, is possible for evacuation of collections of pus, or the removal of foreign bodies in the bronchi. A rectangular musculocutaneous flap is raised, portions of two or three ribs re- sected, and the pleura carefully stripped from the posterior wall and bodies of the vertebra?, after which the posterior mediastinal space is exposed by carefully retracting the pleural sac outward. Methods of Avoiding the Dangers of Pneumothorax in Operations Upon the Lung and Mediastinal Organs. — While an uncomplicated unilateral pneumothorax is not a source of grave danger to an individual with a sound lung on the opposite side, when such a pneumothorax is associated with a serious operation upon the lung or one of the 31 482 DISEASES OF THORAX, PLEURA, AND LUNG mediastinal structures, it adds greatly to the operative risk. When both pleural cavities are opened the result is generally fatal. To avoid the serious consequences of operative pneumothorax, many methods have been devised, including the negative pressure cabinet of Sauerbruch, the elaborate operating chamber of Willy Meyer by which both negative and positive pressure can be employed, and the portable positive pressure cabinet of Janeway and Green. By far the simplest and safest is the intratracheal insufflation method of anesthesia devised by Meltzer and Auer. A number 30 gum-elastic woven catheter is introduced through the glottis well down into the trachea. Through this a current of air is passed by means of a foot-bellows, and rubber tube which is attached to the proximal end of the catheter. By this simple apparatus, artificial respiration can be kept up for many hours without any muscular effort on the part of the patient. If the air from the bellows is passed through a Wolff bottle containing ether, before entering the catheter, an ideal anesthesia is induced, and at the same time any degree of intrapulmonary pressure may be produced and maintained by regulat- ing the amount of air and ether vapor entering the trachea in a given time. By the employment of this method of anesthesia, one or both pleural cavities may be opened in operative approach to any of the intrathoracic viscera without danger of any of the untoward effects of pneumothorax. A number of apparatus have been devised for intratracheal anesthesia with a view to regulating more accurately the intrapulmonary pressure and the percentage of ether vapor, filtering the air and furnishing it with a certain amount of heat and moisture. The apparatus of Elsberg and that of Janeway are in general use and have proved most satis- factory. The latest and perhaps the most accurate of all, however, is the one recently devised by Karl Connell which is described on p. 162. CHAPTER XIX. MALFORMATIONS AND DISEASES OF THE MAMMARY GLAND. MALFORMATIONS OF THE BREAST. Congenital absence of the breast (amastia) is rare, and is usually associated with other anomalies, as absence of the pectoral muscles, or abnormalities in the development of the ribs. Supernumerary breasts {polymastia) are more common and are observed in both males and females. As a rule these aberrant masses of gland tissue occur along a line drawn from the anterior border of the axilla to the middle of Poupart's ligament, although they have been observed on the buttock, vulva, and thigh. Occasionally these glands present rudimentary nipples and they have been known to secrete milk during late pregnancy and lactation. The normal breast tissue often extends upwards toward the axilla, and if enlarged may be mistaken for a supernumerary breast. DISEASES OF THE MAMMARY GLAND. Acute Mastitis. — This is a septic inflammation of the glandular and areolar tissue of the breast. It may occur in either sex, but is far more common in women. Although acute mastitis may arise from wounds and other traumata, and from infection conveyed from other parts by means of the bloodvessels or lymphatics, in the great majority of instances the disease arises in nursing women, and is due to infection of the milk ducts from an inflamed and fissured nipple. Symptoms. — The symptoms of acute mastitis are pain, tenderness, and an increased sense of weight and heat in the breast, with superficial redness and edema of the skin. On palpation one or more hard, tender lumps may be felt in the breast; or the entire gland may, rarely, be the seat of a massive induration. Often there is a chill at the beginning of the infection, with elevation of temperature and pulse rate, localized pain and a general feeling of malaise. The occur- rence of indurated areas in the breast of a nursing woman without fever or other evidences of constitutional disturbance is frequently ob- served, and is due to an oversecretion of milk which is not regularly removed by the nursing infant. In these cases massage, hot applica- tions, and the use of the breast pump will cause the indurations to disappear, and the secretion soon accommodates itself to the needs 484 DISEASES OF THE MAMMARY GLAND of the child. If, however, this "caking of the breast" is neglected, if often gives rise to genuine mastitis. Acute septic mastitis may in some instances under early appropriate treatment subside, the individual areas gradually disappear, and the breast tissue return to its normal condition. In most cases, however, the disease progresses, and suppuration occurs in one or more regions in the gland. If the suppuration is superficial, it is indicated by a deep- red or purple discoloration of the skin, which is raised and presents an area of softening and fluctuation. If the suppuration occurs deep in the tissue of the breast, these signs may be wanting. The presence of pus is indicated by continued pain, fever, chills, sweats, a leucocytosis and a failure of the induration to subside after a reasonable time. If the suppuration takes place beneath the breast — submammary abscess — the entire gland is raised as if on a water-bed and is abnormally movable on the chest wall, fluctuation often can be detected around the periphery of the gland, and occasionally by placing a hand on either side of the breast a wave of fluid may be appreciated beneath the gland. Treatment. — In the early stages, hot fomentations applied every three or four minutes for half an hour, three or four times in the course of the day, with rest in bed, saline cathartics, and removal of the breast milk, occasionally will cause the symptoms to disappear. If the disease progresses and suppuration occurs, nursing should be stopped and the pus evacuated early by free incisions radiating from the nipple to avoid cutting the large milk ducts. Several incisions often are neces- sary, and when the abscesses are deep the intervening tissue should be broken down by the finger, the cavity freely irrigated, treated with hydrogen peroxide, packed with sterile gauze, or drained with rubber tubes. The use of Bier's suction cups in acute abscess of the breast is often of the greatest service, as it enables the surgeon to make smaller incisions, frequently does away with the necessity of drainage- tubes or packing, and shortens the duration of treatment. If the suppuration is beneath the breast, the incisions should be made around the periphery. It occasionally occurs that a breast may be so completely destroyed by suppuration and the resistance of the indi- vidual so reduced by the prolonged toxemia that complete removal of the gland is necessary. Mastitis Neonatorum. — The breasts of newborn infants occasionally are enlarged and present the signs of a subacute inflammation. The condition is unimportant as they never suppurate unless irritated or are infected as a result of careless treatment. Mastitis Adolescentium. — Swelling, induration, and redness may occur about the nipple and areola at puberty in both male and female children. The condition is not due to infection and subsides sponta- neously in a few weeks or months. Chronic Mastitis. — Chronic mastitis occurs in two forms, one fol- lowing an acute attack of the disease, and one arising independently of infection. DISEASES OF THE MAMMARY GLAND is.", In the first variety, after an acute or subacute mastitis with or without suppuration, more or less extensive areas of induration may persist for years after disappearance of the acute symptoms, some- times causing neuralgia and pain from the pressure of clothing. Occa- sionally the pain and discomfort in these eases are extreme, and often they are aggravated at the menstrual epoch. In the second variety, chronic interstitial mastitis, the entire breast may be affected by an overgrowth of the interstitial fibrous tissue, which is associated with a general atrophy of the glandular substance. In these cases the breast feels lumpy on palpation, and numerous indurated areas are present, usually oblong and fusiform in shape, running from the periphery toward the nipple. This condition in reality is only an exaggerated type of the normal fibrosis and glandular atrophy of the menopause. There is a growing belief among surgeons that the chronic irritation of chronic mastitis of the localized indurated type, favors the subse- quent development of malignant disease in a breast. Treatment. — In all cases in which doubt exists regarding the nature of a hard nodule in the breast it should be removed and subjected to microscopic examination. Galactocele. — A galactocele is an oval cystic tumor filled with milk. Formerly it was thought to be a distended milk duct due to occlusion of its lumen, but later histologic study, which fails to show the presence of epithelium in the cyst wall, tends to confirm the view of Lecene that it is a chronic abscess cavity into which milk ducts have opened. While these tumors occur most frequently near the nipple, they may be found in any part of the gland. In the majority of instances they develop during lactation. After a certain length of time the fluid constituents of the milk may become partly absorbed, leaving a thick, creamy, semisolid mass, resembling tuberculous pus. The condition is an exceedingly rare one and occasionally is mistaken for new growth. As a rule, the disease gives rise to no painful symptoms, and its presence is discovered by accident. Treatment. — The treatment should consist in evacuation of the cyst by incision or trocar, and the application of pure carbolic acid to its walls; or by complete removal. Syphilitic Lesions of the Breast. — An initial lesion may occur on the nipple of a woman nursing a syphilitic child not her own. As in other situations, the disease appears as an indolent indurated ulcer with marked axillary gland enlargement. Mucous patches, mucous tubercles, and condylomata may also occur in the secondary stage of the disease, about the nipple or the areola, and upon the raw surfaces of pendulous breasts. Gummata are comparatively rare. When they occur in the gland tissue they must be distinguished from new growths. This generally is easy by recognizing the peculiar elastic consistence of the tumor, by the history and presence of other evidences of the 4s.; DISEASES OF THE MAMMARY GLAND disease, by the Wassermann reaction and by its rapid disappearance under appropriate treatment. Tuberculosis of the Breast. — Tuberculosis of the breast may occur as a cutaneous lesion — lupus— which has already been described, or as a localized or diffuse tuberculous inflammation of the gland. In the localized form there may be a single slow-growing hard tumor with enlargement of the axillary lymph nodes. The tumor is not sharply circumscribed and the disease may be mistaken for carcinoma. The tumor is made up of a mass of indurated inflammatory tissue, in the centre of which is a softened area containing caseous material or Fig. 258. — Tuberculosis of the breast. pus. Enlarged lymph channels may be traced from the tumor to the axillary nodes, many of which may be enlarged and cheesy. In the diffuse form of the disease, which is usually secondary to tuberculosis elsewhere, the entire gland may be filled with caseating nodules, which later break down and discharge upon the surface, leaving sinuses and the characteristic cutaneous lesions (Fig. 259). Bloodgood's statement, that all abscesses occurring spontaneously in the non-lactating fe- male breast are tuberculous in character, is generally borne out by experience. Treatment. — The treatment of tuberculous lesions of the breast is by complete excision of the diseased area, with the lymph channels and nodes. This often demands amputation of the gland and careful DISEASES OF THE MAMMARY GLAND 487 dissection of the axilla. Incision, with curetting, and packing with iodoform gauze, has been recommended, but is uncertain in its results. \ Flo. 259. — Paget's disease of the breast. Paget's Disease of the Nipple. — Paget's disease is an obstinate form of dermatitis of the nipple and areola, occurring generally in women about the menopause, and is followed by epithelioma and duct cancer. The disease is rare. It is characterized by a superficial area of erosion of the skin, which is red and tender. It begins on the nipple or the areola, and may extend for a variable distance in the skin covering the gland. It re- sembles eczema in appearance. There is a small amount of se- cretion, which dries and forms scabs or crusts. There is often a burning or itching sensation. It differs from simple eczema in that its borders are more sharply defined and often slightly raised, and is not relieved by usual methods of treating eczema. The treatment of this con- dition when the diagnosis is established should be complete removal of the gland. Diffuse Virginal Hypertrophy of the Breast. — A rare condition occur- ring at or near puberty, characterized by a bilateral hypertrophy Fig. 260. -Diffuse virginal hypertrophy of breast. 488 DISEASES OF THE MAMMARY GLAND of the breast tissue. In the majority of instances the increase in size is due almost wholly to an overgrowth of the fibrous elements of the breast, although later in life these breasts show a certain amount of glandular hyperplasia. The abnormal growth is gradual and, as a rule, is unaccompanied by pain or discomfort other than an increased sense of weight. The breasts may grow to an enormous size and give rise to great deformity (Fig. 2G1). Treatment. — The treatment in the early stage should consist in support by bandages; when the disease has progressed to the stage of discomfort, partial or complete amputation is to be advised. Fig. 261. — Chronic cystic mastitis. Senile Parenchymatous Hypertrophy. — This condition has been extensively studied by Koenig, Reclus, Schimmelbusch, Warren, and Bloodgood, and many different ideas regarding its pathology have been expressed. It has been thought to be a chronic inflammation, a new growth, and a degenerative change; hence the terms chronic cystic mastitis, cyst-adenoma of the breast, and abnormal involution have been applied to it by different observers. Next to carcinoma it is the most frequent pathological condition found in the female breast after thirty-five. It occurs generally at or near the menopause, and is characterized by an overgrowth of connective tissue and the formation of innum- erable large and small cysts. It may involve only a part of one breast or the greater portion of both glands. Two types are recognized, one in which the cysts are thin walled and contain turbid or brownish fluid, the other in which many of the TUMORS OF THE BREAST 489 alveolar spaces and cysts are filled with an overgrowth of epithelium, forming adenomatous masses. Both varieties are prone to undergo carcinomatous degeneration, but this tendency is much more marked in the adenomatous type. Symptoms. — The symptoms of this disease arc those of a slowly developing, irregular mass in the substance of the breast without pain, retraction of the nipple, adhesion to the muscle or skin, and with- out involvement of the axillary nodes. To the examining hand the mass often resembles carcinoma, in that it is diffuse and fades away gradually into the surrounding tissues. Occasionally fluctuation can be detected if a large cyst is present near the surface. Not in- frequently two or more masses may be detected in the same breast, and bilateral involvement is not uncommon. The tendency of this disease to undergo malignant change renders treatment by removal of the entire gland imperative. TUMORS OF THE BREAST. The female breast is frequently the seat of tumor. It has been estimated that one-fifth of all tumors, both innocent and malignant, occur in the breast. While innocent tumors occur with a fair degree of frequency in the breast, the number of malignant growths in this gland is so great that the proportion of the latter is three to one of the former. As a general rule, it may be stated that the innocent tumors develop early in life, the malignant at a later period; to this, however, there are many exceptions, as cancer has frequently been observed between the ages of twenty and thirty, and sarcoma and adenoma may occur at any age. It must also be remembered that many of the so-called innocent neoplasms have a potential malignancy, in that they not infrequently develop malignant characteristics if allowed to remain in the breast until middle life or old age. Tumors of the breast may be divided into three chief groups, the fibro-adenomata, the sarcomata, and the cardnomata. Other varieties are exceedingly rare. Lipomata, angiomata, endotheliomata, chon- dromata, lymphatic, and hydatid cysts have been reported. Fibro-adenoma. — Adenoma is a tumor composed of a mass of of glandular tissue surrounded by a fibrous capsule. Adenomata may rarely occur as single or multiple tumors in one or both breasts. They are rounded in shape, hard and elastic to the touch, are freely movable, do not become adherent to the skin or muscle, are not accompanied by enlargement of the axillary lymph nodes, and show no tendency to recur after complete removal. These tumors vary in size from that of a hazelnut to that of an orange, or even larger. They occur in the majority of instances during the menstrual life of the individual. They are rare after fifty, and have not been reported before the thirteenth year of life. In the great majority of adenomata 490 DISEASES OF THE MAMMARY GLAND there is an overgrowth of connective tissue, and to these tumors the term fibro-adenoma has been applied (Figs. 262). When the epithelial elements are active, fluid may be secreted in one or more of the glandular acini and cysts are formed. To describe this variety the term cyst-adenoma or adenocele has been employed. In other instances the tumor is made up almost entirely of myxomatous fibrous tissue which surrounds the ducts and acini, and masses of this tissue may project into the ducts, giving rise to the term intracanaUcular myxoma. Occasionally one portion of a tumor may be distinctly fibrous and another glandular and cystic. These tumors are often spoken of as fibrocyst-adenomata. Small tumors occasionally develop in the walls of the ducts, project into the lumen, and give rise to a Fig. 262. — Fibro-adenoma of female breast. collection of fluid, causing a fusiform dilatation. Often they have a papillomatous appearance, and are spoken of as intracanalieidar adenoyaj) Mom a ta . These tumors, as a rule, produce no symptoms; they are generally discovered by accident and their growth is exceedingly slow. There is positive evidence to show that in certain rare cases these tumors, after remaining for a long period of time as stationary or slowly developing innocent growths, may suddenly change their character, grow rapidly, and become converted into malignant neoplasms. Three such examples came under the author's observation in one year. Diagnosis.— Fibro-adenomatous tumors are to be distinguished from carcinomata by the fact that they are of slow growth, are dis- tinctly circumscribed, are freely movable, and not adherent to the skin or muscle, are not accompanied by retraction of the nipple or TUMORS OF THE BREAST 491 axillary involvement; from the sarcomata, by their slow growth and comparatively small size, and by the fact that they are frequently multiple; from chronic mastitis, by their round shape, their distinctly circumscribed borders, and by evidences of encapsulation. Treatment.- On account of the possibility of these tumors becoming converted into malignant growths, their removal should be advised in all cases. As a rule, this is accomplished best by an incision radiating from the nipple or around the periphery of the gland. In the majority of cases, especially when the tumor is located near the periphery, the latter method should be employed. By making a curved incision around the outer, or outer and inferior border of the gland, the breast may be turned upward and the growth approached from its under surface. The tumo'r when exposed is easily enucleated. In certain cases when multiple tumors exist or when there is extensive cystic disease removal of the entire gland is advisable. Sarcoma. — Sarcoma is a comparatively rare disease of the breast. It occurs in tw r o forms, the round-cell, rapidly growing variety, which later infiltrates the breast tissue; and the type which not infrequently develops on a pre-existing intracanalicular myxoma. The former is exceedingly malignant, occasionally involves the axillary lymph node, and is disseminated by the blood current; the latter is less malignant, is often cured by early and complete removal. Diffuse sarcoma arises from the connective tissue of the gland, and its growth often includes portions of the glandular substance, which may later develop into cysts, forming the type known as cystosarcoma. Secondary myxomatous changes may rarely occur and when this occurs the tumor is spoken of as a myxosarcoma. Cartilage is occasion- ally found in these growths, as in those of the parotid gland, giving rise to the term chondrosarcoma. In the encapsulated less malignant type, which comprises about 80 per cent, of all breast sarcomata, the disease may exist for years as a benign growth; it then increases rapidly in size, apparently breaks through its capsule, and invades the tissues of the gland. This change often is evidenced by a bluish discoloration of the skin, which later ulcerates and develops into a fungating mass. Breast sarcoma occurs, as a rule, in individuals under fifty years of age. Its growth is, in the early stages, painless, but in the case of the round-cell variety exceedingly rapid. Nursing seems to exert a stimulating influence upon the growth of breast sarcomata, as they progress with great rapidity during lactation. Diagnosis. — The diagnosis of sarcoma of the breast is by no means always an easy matter, and in certain cases impossible before a micro- scopic examination is made of the tissue. The chief clinical points are its rapid growth, the age of the patient, and the late involvement of the lymph nodes. The encapsulated myxo-sarcomata resemble at first the fibro-adenomata in being sharply circumscribed tumors, and occasionally cystic; they differ, however, in that they grow much 492 DISEASES OF THE MAMMARY GLAND faster, attain a large size, and are always single. The round-cell infiltrating sarcomata may closely resemble the rapid and cellular carcinomata (Plate XVII). Absence of enlargement of the lymph nodes would favor the diagnosis of sarcoma; if these an- involved, the diagnosis must rest in doubt until the ti>>ne can he examined microscopically. Treatment. — Early and complete removal is the only rational treatment of this disease. In the slowly growing myxosarcomata the entire breast and axillary glands should be removed; in the nmre rapidly growing diffuse sarcomata the complete Halsted operation should be performed. These measures, if carried out at an early period of the disease, often will bring about a radical cure; and it should be remembered, moreover, that a local return of the growth often may be successfully treated by surgical means even after three or four recurrences. In the rapidly growing round-cell variety the progno-i- i- always grave, as dissemination of the disease by the blood current occurs at an early period, and operation-^ which are at all delayed are apt to give but temporary relief. In inoperable sarcomata of the breast and in extensive recurrences the x-rays offer a chance of improvement, arrest of the growth, or radical cure. The use of erysipelas toxin in these cases has been followed by success in a few instances. Carcinoma. — Carcinoma is by far the commonest disease of the female breast. It is more frequently encountered than sarcoma, the proportion being about 12 to 1. If we exclude the uterus, certainly no organ in the female body is as frequently the seat of cancerous disease a- the breast. The disease may rarely occur in the male breast. Regarding the age at which it develops, it may be stated in general that it is a di-ea>e of late middle life, the greatest number of cases occurring in individuals between forty and fifty years of age. It, however, may occur at any earlier period, and several instances are on record of the disease in women between fifteen and thirty. The influence of the married state, pregnancy, and lactation is ap- parently unimportant in the etiology of cancer, but carcinoma occur- ring in a breast during pregnancy invariably assumes an extremely malignant type. Heredity plays a certain part in the etiology, and there is -ome evidence to suggest that contagion may be an important factor. The history of a blow or other trauma is misleading, as few women reach the cancer age without suffering such injuries. Irritation of the gland, produced by the presence of other new growths or of a chronic mastitis, is thought by many observers to favor development nf this disease. Carcinoma of the breast may arise from the glandular elements or from the milk ducts. The former is called acinous cancer; the latter, duct cancer. Acinous cancer, which is by far the commoner variety, occurs in two forms: the hard fibrous carcinoma or scirrhus, and the soft cellular variety or encephaloid cancer. PLATE XVII Ulcerating Sarcoma of Breast. TUMORS OF THE BREAST 493 Scirrhous cancer of the breast is the commonest form of the disease. It may begin in any part of the gland, but is more frequently seated near the nipple or in the upper and outer quadrant. 1 When first noticed, it is usually an oval, deep-seated, indurated movable lump of stony hardness. It is not sharply circumscribed, and as it develops it can be felt to grow outward into the surrounding tissues, which gradually become more infiltrated and dense. Adhesions soon form between the tumor and the skin, and also with the underlying Fit muscle. The nipple is frequently retracted, and the axillary lymph nodes become enlarged. The latter occurs early in the disease, prob- ably about the second month, but owing to the location of the glands and the surrounding fatty tissue, they are rarely recognized until a 1 It must be remembered that the upper angle of the breast, which normally extends toward the axilla along the lower border of the pectoral muscle, is occasionally sur- mounted by_an oval mass of glandular tissue, or such a mass may exist without direct glandular connection with the breast, resembling a supernumerary mamma, in which carcinoma may develop. 494 DISEASES OF THE MAMMARY GLAND later period. As the growth of the tumor advances and the surrounding tissues are infiltrated, an atrophy or shrinkage of the entire gland may occur in certain cases, from contraction of the fibrous tissue, giving rise to the variety sometimes called "withering cancer" (Fig. 263). In the majority of instances, however, the growth involves a large part of the gland, the overlying skin, and the underlying muscles and chest- wall. If allowed to progress, the subcutaneous lymph spaces may become infiltrated with the disease, which results in a hardening of the skin with the formation of numerous dense white nodules. When this extends over a large area of the chest wall, respiration may be embarrassed, and the condition is spoken of as cancer en cuirasse. Fig. 264. — Ulcerating carcinoma of breast. As the growth progresses the lymphatics of the axilla and supra- clavicular region enlarge, forming later massive tumors which press upon the vessels and nerves and cause edema of the arm and neuralgia in the branches of the brachial plexus. In most cancerous growths of the breast the first lymph nodes to become involved are those lying along the inferior border of the great pectoral muscle. Exceptionally, when the disease first attacks the upper and inner quadrant, the medi- astinal nodes are primarily affected, chiefly through lymph channels entering the thorax through the second intercostal space. Lymphatic edema may occur from obstruction of the lymph channels, producing a condition of the skin of the upper extremity and shoulder resembling PLATE XVIII Ulcerating Carcinoma of Breast. 'Lumiere Photograph.) TUMORS OF THE BREAST 495 elephantiasis, which often renders the arm practically useless from its increased weight. Encephaloid cancer presents a very different clinical picture. The growth occurs as a soft, elastic, rapidly growing tumor, which soon infiltrates the entire tissue of the breast and does not produce retraction of the nipple. The disease early infects the lymphatics and infiltrates the skin, which becomes discolored and breaks down, leaving a foul, rapidly f ungating ulcer (Fig. 2G4). Rapid dissemination of the disease takes place, which speedily leads to a fatal termination. Duct cancer is the rarest and least malignant form of the disease. It occurs as a small, slowly developing papillomatous tumor growing from the walls of a dilated milk duct, usually near the nipple. It occurs generally about the menopause, when the glandular structure of the breast atrophies and the galactophorous ducts are prone to enlarge, forming a general cystic condition of the breast. The tumor is softer than the scirrhous variety, is often covered by a bluish or purplish skin, and on section is found to be surrounded by a capsule made up of the walls of the dilated duct. Symptoms. — The early growth of a carcinoma of the breast is, as a rule, unaccompanied by symptoms of any kind. Pain is rarely present until the disease has extended to the axillary lymph nodes and produces pressure on the nerves. In the earlier stages of scirrhus and encephaloid a sense of weight in the breast may be experienced by the patient; and in neurotic subjects, shooting pains, burning sensations, and other forms of paresthesia may be present. Genuine pain, shooting into the breast and down the arm, is a fairly constant late symptom, which may be so severe as to cause great suffering and to necessitate the use of opiates. The presence of an intermittent bloody discharge from the nipple is one of the earliest signs of duct cancer. Loss of weight and strength, anorexia, anemia, and a peculiar sallow, unhealthy appearance of the skin develop late in the disease, and are due to absorption of toxins or to secondary involvement of other organs. As this cachexia develops the patients become bed- ridden and exhausted, and eventually die of asthenia. Metastasis in cancer of the breast is common. It occurs most frequently in the liver, lungs, pleura, and bones, particularly the spine, sternum, femur, and humerus. More rarely metastases occur in the abdominal organs, or central nervous system. Formerly these secondary deposits were thought to be largely due to transmission of cancer cells by the general circulation, after extension of the disease to the blood from the axillary lymphatics. Handley, however, has recently shown that extension of the disease takes place to a larger extent by direct growth of columns of cancer cells, along the deep fascia often without visible involvement of the superficial layers of the skin, and that these prolongations of the disease direct from the parent growth may reach the liver by means of the round ligament; the humerus, sternum, clavicle, spine, and femur at points where the deep fascia is attached to these structures. 490 DISEASES OF THE MAMMARY GLAND It is a significant fact that these metastatic deposits are often present without the occurrence of pulmonary lesions, which would be difficult to explain if the old theory of blood dissemination were true. Diagnosis. — While accurate diagnosis is a comparative simple matter late in the disease when all the characteristic symptoms and signs are present, in the earlier stages, when treatment offers a chance for radical cure, the diagnosis is often attended with con- siderable difficulty. The presence of a hard tumor in the breast of a women over thirty should always be regarded with suspicion. If the growth progresses rapidly, is single, and is early associated with retraction of the nipple, enlargement of the axillary lymph nodes, or dimpling of the skin over the centre of the mass, the prob- abilities are that it is carcinomatous in character. If in addition to this, the growth infiltrates the gland without distinctly circumscribed limits and the overlying integument assumes the appearance of "pig skin," or dense lymphatic infiltration, the diagnosis is certain. In differentiating between an early cancerous nodule and chronic cystic mastitis, the fact that the nodule is single and its growth pro- gressive would favor the diagnosis of cancer; the absence of any sharp line of demarcation between it and the surrounding breast- tissue would serve to distinguish it from an adenomatous tumor. This fact would also enable one to exclude encapsulated spindle-cell sarcoma, while the comparatively slow growth and limited extent of a beginning scirrhous carcinoma would distinguish it from the rapidly growing, infiltrating, round-cell sarcoma. There are, however, no distinguishing features which will enable one to differentiate between an encephaloid carcinoma and a round-cell sarcoma, unless it be that the growth of the latter is more rapid and unaccompanied by enlarged lymph nodes. In all doubtful cases early and complete removal of the suspicious nodule is to be recommended. This should always be effected without cutting into the diseased mass. Under favorable conditions the tumor may be immediately examined by means of frozen sections, and if its malignancy is demonstrated the complete operation can be performed at once. When frozen section examination by a competent pathologist is not possible, the safest course to pursue in all growths of doubtful character is by radical operation. Prognosis. — In general it may be stated that the disease if un- treated always leads to a fatal termination. The more cellular the growth the more rapid its course. In cases of "withering cancer" or the exceedingly slow-growing duct cancers the progress may lie so delayed that death not infrequently takes place from other causes. The average duration of life in an untreated case of encepha- loid carcinoma of the breast is from nine to eighteen months; in ordinary scirrhus, from two to three years. The prognosis in cancer of the breast treated by modern operative measures has steadily improved during the past twenty years. In general, it may be stated that TUMORS OF THE BREAST 197 the operative mortality should not be over 3 per cent., and the three- year cures should be upward of 30 per cent. In selected early cases, where the growth is small and no enlarged lymph nodes can be felt in the axilla, the percentage of cures is between 60 and 70. Treatment.— As soon as the diagnosis of carcinoma of the breast is established, complete removal of the disease should be under- taken at the earliest possible moment. While some surgeons still advise simple removal of the gland and the axillary contents in cases of early fibrous carcinoma, statistics prove that the general employ- ment in these cases of the complete Halsted operation is followed by a larger percentage of cures than when any other method is adopted. This method is applicable to all cases of carcinoma of the breast when the disease appears Jimited to the mammary gland and the axillary lymph nodes. If the growth is small and the lymph nodes but little if any enlarged, removal of the breast, the pectoral muscles, and the areolar tissue of the axilla will be sufficient. If, however, the axillary nodes are extensively involved, and especially if the lymphatics high up in the axilla under the tendon of the pectoralis minor muscle are diseased, the supraclavicular space must be exposed and cleared of its lymphatics and areolar tissue. If the disease has involved the chest wall, the great vesssels of the axilla, and large areas of the skin (cancer en cuirasse), or if the supraclavicular lymph nodes can be felt, the operation should not be undertaken with a view to radical cure of the disease, although in certain cases this or less extensive operations are justifiable as palliative measures. In a recent publica- tion Barker states that "the more localized the primary focus of carcinoma in the breast is, the more wide-reaching should be the excision; that is to say, there is in such cases a fair prospect of complete eradication of the disease by a wide-reaching operation. The converse rule appears also to have much to recommend it, viz., that the more wide-reaching the disease, the more clearly should the operator keep palliation in view, and by limiting his operation avoid the risk of extreme shock." The operation for complete removal of the female breast is carried out as follows: The axilla should be shaved and the entire region of the neck, shoulder, upper arm, breast, and side wall of the chest should be prepared in the usual manner. After the patient is anes- thetized the arm of the affected side should be held at a right angle with the body, and an incision made from the humeral insertion of the pectoralis major tendon over the point of the shoulder and then downward on the chest wall to the inner side of the nipple to a point two or three inches below the lower margin of the gland; from the upper portion of this cut another incision is carried downward along the edge of the pectoral muscle and then curving inward to meet the lower extremity of the first incision; or if the disease is more extensive and it is desirable to remove a larger area of skin, the incision is modified as seen in Fig. 265. This incision is carried through the skin and 32 498 DISEASES OF THE MAMMARY GLAND superficial fascia, which are dissected free on either side to the muscular layer, exposing the pectoral muscle throughout over its entire length. The tendon of the muscle is next separated from its attachment M Mm m?>> mBSSmBHm / i I I Fig. 265. — Halsted's breast operation, skin incision. to the humerus and retracted downward (the clavicular fibres may be left), and the attachment of the pectoralis minor muscle exposed and severed (Fig. 26(3). The axillary space thus exposed is cleaned from Fig. 266. — Halsted's breast operation, later stage. above downward of all fascia, lymphatics, and areolar tissue, care being taken when the lower limit is reached to preserve if possible the subscapular and posterior thoracic nerves. When the axillary TUMORS OF THE BREAST 499 space is thoroughly cleared, the costal and sternal attachments of the pectoralis major muscle are divided, as well as those of the pectoralis minor, and the entire mass, consisting of the breast, both muscles, and the axillary glands and areolar tissue, is removed. If the supraclavicular space is to be explored, a curved or straight in- cision is made above the clavicle, and the lymphatic structure and areolar tissue removed along the subclavian vessels and for a distance of two or more inches above the clavicle behind the sternomastoid muscle. When this is accomplished, the wounds are closed as com- pletely as possible with silk or silkworm-gut sutures, and the remain- ing uncovered portion immediately covered with Thiersch skin-grafts taken from the thigh or arm. A small opening for drainage should be cut through the axillary flap and a small cigarette drain introduced, after which a large gauze and cotton dressing should be applied and the arm fixed at a right angle across the chest, and the whole held by a large many-tailed bandage. As a rule, there is little reaction after the operation if care is taken to avoid hemorrhage and infection. Often the patients are allowed to sit up on the fifth or sixth day. If the temperature remains normal, the dressing need not be removed for ten days. In inoperable carcinoma and in extensive local recurrences of the disease, the use of the .r-rays, and especially the improved therapeutic rays generated by the new Coolidge tube, may be employed. The marked improvement following this treatment, in seemingly hopeless cases, has led the author to advise a series of treatments by this method as a prophylactic measure immediately after recovery from a radical operation, in all cases of breast cancer. CHAPTER XX. INJURIES OF THE ABDOMEN. Contusions. — Contusions of the abdominal wall are of frequent occurrence, resulting from all manner of traumata. They vary in their results from a slight feeling of soreness and general discomfort to a rapidly fatal collapse. This difference, which is observed not infrequently in injuries quite similar in their method of production, in the amount of force expended, and in their outward signs, is due to the presence or absence of associated internal or visceral injury. The effects of a blow on the anterior abdominal wall are modified by the condition of the abdominal muscles. An unexpected blow on the pit of the stomach received while the muscles are in a state of comparative relaxation is often followed by severe shock, nausea, and temporary muscular weakness, due, as Crile has shown, to the concussion being transmitted to the pericardial portion of the dia- phragm. If, however, the blow is expected and the abdominal muscles are rigidly set, little or no inconvenience is produced. The same is true of other parts of the abdomen; an expected blow or contusion produces, as a rule, less visceral injury than one received while the abdominal wall is relaxed. A blow directly over a distended hollow viscns, as the stomach, intestine, or urinary bladder, may cause a rupture and extravasation of the contained matter, while a like blow received when the organ is in a state of collapse may produce no untoward effect. Enlargements of the liver and spleen to such an extent that they lie below the protecting arches of the ribs, favor their injury as a result of abdominal trauma. It must be remembered that extensive and fatal visceral ruptures may be produced by com- paratively slight contusions; that the amount of internal injury is due more to the condition of the organ and the protecting abdominal muscles than to the force of the blow. The extraperitoneal results of abdominal contusions are: bruises of the skin; subcutaneous ecchymoses; hematomata beneath the skin, between the muscular layers, or between the muscles and the peritoneum; rupture of the muscles at their points of attachment or in the intervening portions; contusion or rupture of the kidney. The intraperitoneal injuries may be: contusion and rupture of the parietal peritoneum; contusion or rupture of the stomach or intestine; contusion or rupture of the liver, spleen, or pancreas; and injury to the omentum or mesentery. Ruptures of the bladder may or may not involve the peritoneal cavity. In rupture of any portion of the CONTUSIONS 501 alimentary canal, extravasation of the contained matter will result, producing immediate peritoneal irritation, as evidenced by pain, tenderness, thoracic respiration, retracted abdomen and muscular rigidity, and later will be followed by septic peritonitis. In regard to the varying degrees of peritoneal irritation produced by the extravasation of material from upper or lower portions of the alimentary canal, it may be stated that the intensely acid gastric juice, and the pancreatic secretion produce a greater degree of peri- toneal irritation than the contents of the lower bowel. This is evi- denced by a more acute initial pain, and a higher degree of muscular spasm. Injuries of the liver or spleen following abdominal contusions are generally found to be more or less extensive fractures, which result in extravasati'on of blood, which varies in amount with the extent of the injury. Such hemorrhages are indicated by a condition of shock and by more or less localized peritoneal irritation. In the rare ruptures of the pancreas from abdominal contusion, the sudden occurrence of glycosuria is strongly suggestive. Injuries of the omentum and mesentery are rarely found unassociated w r ith visceral injury. If their larger vessels are wounded, extensive hemor- rhage will result. A distended bladder may be ruptured by a blow over the hypogastrium, but the injury is associated more often with fracture of the pelvis. Diagnosis. — Contusions of the abdomen are apt to be associated with a condition of early and transitory shock which does not nec- essarily point to visceral injury. If the results of the injury are limited to the abdominal wall, the symptoms w r ill be those of con- tusion and laceration of other muscular structures, which are sore- ness, pain on motion, and tenderness to pressure. If an hematoma forms, it will be indicated by the presence of a more or less circum- scribed tumor, which, if superficial, will fluctuate, and if situated deeply beneath the thick muscular layers, may simply impart to the examining hand a sensation of elasticity. Occasionally an extensive retroperitoneal hemorrhage in the flank may be felt from in front as a deep-seated abdominal tumor. If, following an abdominal contusion with or without signs of superficial injury, there is progressively increasing shock, indicated by pallor, nausea, cold extremities, and a weak pulse increasing in rapidity, with localized or general abdominal pain and an appre- ciable rigidity of the muscles which is not accounted for by local injury, the case is in all probability one of visceral injury. If, in addition to the above symptoms, there is evidence of free fluid in the peritoneal cavity, indicated by dulness or flatness in the flanks, which disappears on turning the patient on the opposite side, or if free gas is present in the peritoneal cavity, evidenced by oblit- eration of the liver dulness, and if the first depression is followed by gradual rise in temperature, with an increasing pulse rate, the diagnosis is rendered still more probable. If these symptoms are 502 INJURIES OF THE ABDOMEN all progressive and the patient passes rapidly into a state of profound collapse, the diagnosis is certain. Severe localized pain with marked rigidity over the epigastrium points to a rupture of the stomach or injury to the pancreas; pain and tenderness limited to the right hypochondrium with evidences of free fluid suggests a rupture of the liver; the same on the left side suggests a rupture of the spleen; pain and rigidity about the umbilicus or in the lower part of the abdomen, without other symptoms, suggest rupture of the intestine; pain in the hypogastrium, with tenesmus and the passage of bloody urine or an empty bladder, indicates rupture of that organ; while pain in the flank, with hematuria and a retro- peritoneal exudate, suggests contusion or rupture of the kidney. In cases of visceral injury the symptoms and signs are rarely so localized a- to warrant a positive diagnosis as to the nature of the lesion, and in many cases the symptoms are so mild, obscure, or misleading that the presence or absence of such lesions may only be surmised. In all cases of doubt the indications are for an immediate laparotomy for purposes of exact diagnosis and treatment, as the symptoms and signs in many cases give no indication of the extent and gravity of the lesion. 1 Treatment. — The treatment of simple contusions of the abdominal wall consists in rest and the application of hot stupes or other soothing measures. If an hematoma develops beneath the skin or between the muscles, the rest should be continued until the fluid is absorbed. In large hematomata aseptic aspiration of the fluid with subsequent compression will often materially shorten the duration of treatment. If there is evidence of continued extravasation of blood, which is not controlled by pressure, the part should be exposed by incision, the bleeding vessel ligated, or the hemorrhage arrested by gauze packing. Hematomata in the flank associated with rupture of the kidney, frequently become infected, giving rise to extensive suppuration, which -hould be treated by incision and drainage. In the 'presence of symptoms indicating visceral injury or severe intra-abdominal hemorrhage, the patient should be immediately prepared for operation. In addition to the usual preparation, the patient, if in severe shock, should be given morphine j grain and strychnine ^V, grain half an hour before the operation. Fifteen minutes later he should have an enema of hot coffee, which should be held in the rectum until his removal to the operating-table. When the patient is etherized, an intravenous saline infusion should be started before the abdomen is opened; or better still, in cases of profound 1 On two occasions the author has found on exploratory laparotomy complete rupture of the small intestine, the only indications of which were the history of injury, a rapid pulse, and slight tenderness and rigidity of the abdominal wall. On another occasion a transverse rupture of the spleen was found with over a quart of free blood in the peri- toneal cavity, in an individual who had walked a mile after the accident and complained only of slight abdominal pain and tenderness. There was, however, in each instance, marked muscular rigidity. CONTUSIONS 503 shock associated with evidences of grave hemorrhage, direct trans- fusion of blood just prior to operation will often render a moribund patient operable. When the symptoms point to no definite locality, a median incision should be made and the peritoneal cavity explored. If gas or free blood escapes when the peritoneum is opened, the ab- dominal incision should be widely extended and a search instituted for the injured viscus. In the presence of free gas or intestinal content-. the stomach should be drawn into the wound and inspected, after which the colon should be examined from the cecum to the rectum. If no lesion is found, the small intestine should be lifted out of the abdominal cavity, covered with warm wet towels, and the entire length of the gut inspected from the duodenum to the ileocecal valve. When the lesion is found, it should be repaired if possible by one or more silk Lembert sutures. If, in case of an intestinal injury, the wound is too extensive to be closed in this way without causing stricture, the injured area should be excised and the ends united by a Murphy button or one of the suture methods of end-to-end anas- tomosis. If on opening the peritoneum hemorrhage only is present. the liver and spleen should first be examined for evidences of rupture. If no injury to these organs is found, the mesentery, greater and lesser omentum, vena cava, pelvic vessels, and abdominal parietes are ex- amined in the order given. This examination is greatly facilitated by removal of the small intestine from the cavity and the use of large gauze sponges in sponge-holders to wipe away the blood from the various parts of the abdomen. Rupture of the liver should be treated by suture of the rent where this is possible. Mattress sutures of heavy catgut should be employed, introduced by a blunt curved needle or by a curved silver probe, the needle or probe entering the hepatic tissue at a considerable distance from the edge of the fissure. Where this is impossible, or would require too much time or manipulation, the use of generous gauze tamponnade is to be advised. As the rent is frequently on the diaphragmatic surface of the right lobe, along the falciform or coronary ligaments, the abdominal wall should be forcibly retracted and the right lobe of the liver gently depressed in order to place the gauze around the injured area. In case a median incision is employed, a separate incision should be made along the lower costal border, through which the external portion of the gauze should protrude. If allowed to emerge through the median incision, its removal would tend to draw downward the right lobe of the liver and thus reopen the fissure. An injured spleen generally can be drawn into the wound and its ruptured surface united with sutures. If this is impossible on account of the condition of the patient the surgeon has the choice of two methods, either to perform a rapid splenectomy, or to press a large mass of gauze into the rent and replace the organ, allowing the outer extremity of the gauze to protrude through a lower lumbar opening. As soon as the abdominal wound is closed the pressure of the other 504 INJURIES OF THE ABDOMEN viscera causes the external surface of the spleen with its mass of gauze packing to press against the diaphragm, preventing further hemorrhage. The author has found this latter method quicker than any other, and has always succeeded by it in arresting hemorrhage. It has the additional advantage of saving an important organ. After the source of the hemorrhage is found and secured, the abdominal cavity should be flushed with a large amount of hot saline solution, and the wound closed with layer, or through-and-through silkworm- gut sutures. The gauze packing should be allowed to remain in place for from seven to ten days. It should be removed under anesthesia, and a small wick of gauze inserted in the lower portion of the wound. In injuries of the omentum or mesentery, the bleeding vessels should be secured, any large rents sutured, and devitalized portions of the omentum removed. Intestinal resection may, rarely, be indicated when the larger branches of the mesenteric arteries are involved. Success in these cases will depend largely upon the speed of operation, the skill of the anesthetist in administering only a small amount of ether, and upon the judicious employment of stimulating measures, especially the intravenous saline infusion. » Wounds of the Abdomen. — Wounds of the abdomen are divided into two classes: non-penetrating wounds, or those involving only the ab- dominal parietes without opening the peritoneal cavity; and 'pene- trating wounds, or those which open the peritoneum. The non-pene- trating wounds differ in no way from wounds of the soft parts in other regions of the body, with the exception that severed muscles and aponeuroses, if not accurately united, will often lead to a weakening of the abdominal wall and favor the subsequent occurrence of hernia. Every wound, therefore, involving one of these tissues should be carefully disinfected and accurately united by layer suture with a view to obtaining primary union. Penetrating Wounds. — Penetrating wounds of the abdomen are, for the most part, caused by stabs or gunshot injuries. Explosions, railway accidents, and attacks by bulls or other infuriated animals, furnish a few examples, but they are so rare as to be justly regarded as surgical curiosities. Symptoms. — As in the case of abdominal contusions, the symptoms of penetrating abdominal wounds depend upon the presence and character of the associated visceral injury. If the wound is a small one and involves only one of the solid organs, as the liver or spleen, and is unaccompanied by severe hemorrhage, there may be no symp- toms other than those of the superficial cut. This is also the case in certain wounds of the alimentary canal, especially those made by the steel bullets of the modern high velocity fire-arms, as the small, clean-cut wound is often plugged by a prolapse of the mucous mem- brane, allowing little or no extravasation of the contents of the gut. Part of the danger in these cases is therefore due to the presence of septic matter introduced from without, which is often so small in WOUNDS OF THE ABDOMEN 505 amount as to give rise to only a localized peritonitis. In wounds involving the pancreas there is always the added danger that the extravasated pancreatic fluid will produce a fat-necrosis in the neighboring parts, which if infected will lead to extensive suppuration and a high degree of toxemia. In more extensive wounds accompanied by a large amount of hemorrhage or the extravasation of a considerable amount of infected material from a wound of the stomach or intestine, the symptoms are those of shock: pallor, weakness, a rapid, feeble pulse, restlessness, thirst, subnormal temperature, and cold perspira- tion, with localized tenderness and muscular rigidity. Later, the temperature rises, vomiting occurs, and if the patient survives the first shock, symptoms of progressive general peritonitis will develop. In larger abdominal wounds protrusion of the intestine, omentum, and sometimes of other intra-abdominal organs may take place. In many of these cases the shock is comparatively slight, and instances are on record in which individuals have walked for a considerable distance with extensive visceral protrusions. Treatment. — All penetrating abdominal wounds should be explored immediately under general anesthesia, if the surgeon is in a position to conduct the operation with competent assistants under conditions of strict asepsis. Protruding viscera should be thoroughly cleansed before being returned to the abdominal cavity, and the original wound, when favorably situated, should be sufficiently enlarged to permit thorough inspection of the damaged area. If free blood or extrav- asated stomach or intestinal contents are seen, the wound should be extended, or another incision should be made in a more favorable locality and the source of the hemorrhage found or the wounded viscus located. The same principles should guide the surgeon in the treatment of these conditions as under other circumstances: hemorrhage should be arrested by ligature of the bleeding vessel or by gauze packing; injuries of the hollow viscera should be sutured, after which the entire peritoneal cavity should be flushed with salt solution and the wound closed with drainage. In stab wounds the injury will be limited to the immediate vicinity of the wound; in gunshot wounds the injuries are generally multiple and widely separated, and in these cases the incision should be sufficiently large to enable the surgeon to inspect thoroughly every part of the abdominal cavity. In gunshot wounds involving the stomach, the posterior wall invariably should be inspected, and in wounds of the pancreas provision should be made for adequate drainage of the pancreatic secretion. It frequently happens that the bullet will so injure the intestine that resection will be necessary. As in operations for ruptures of the viscera, the surgeon should work quickly and methodically, as prolonged exposure on the operating- table is sure to add to the shock, which in many of these cases is severe at the outset. The hypodermic injection of camphor and strychnine, coffee enemata, and intravenous saline infusions often are necessary while the patient is on the table. 506 INJURIES OF THE ABDOMEN The after-treatment of these cases is of the greatest importance. Shock should be combated by judicious stimulation; food should be withheld for twenty-four or forty-eight hours and then gradually administered by rectum or mouth, and pain should be quieted by some form of opiate. In cases of injury of the alimentary canal, if the symptoms are favorable, the bowels should be confined for four or five days. If peritoneal sepsis develops, early intestinal drainage by free catharsis should be induced. When the peritoneum has been severely contaminated, the surgeon should be on the lookout for signs of localized peritonitis, and collections of pus should be opened and drained as soon as discovered. If the case exhibits signs of progres- sive sepsis, intravenous infusions frequently repeated, rectal salines or irrigations, free catharsis, and the hypodermic administration of strychinine, digitalin, camphor oil or pituitrin, and an abundance of nourishing food will be necessary. It frequently happens in both military and civil practice that abdominal wounds have to be treated under conditions in which perfect aseptic technic cannot be carried out. Under these circum- stances small penetrating wounds, especially when produced by the modern high velocity firearms, are better left to nature, than to add the risk of an exploration under conditions of imperfect technic. In cases of severe hemorrhage and large penetrating wounds with extensive visceral injury the surgeon must act even under the most adverse conditions. Generous gauze drainage of the abdominal cavity will often assist in overcoming the infection necessarily produced in these cases. CHAPTER XXI. DISEASES OF THE ABDOMEN. Cellulitis. — Cellulitis of the abdominal wall occurs as a result of wounds, the bites of insects, and from inflammatory conditions about the umbilicus caused by infection of an unclosed urachus or vitello- intestinal duct. It also occurs as an extension outward of an intra- abdominal septic focus, reaching the surface through the inguinal canal, or by direct infiltration of the muscular layers. The symptoms and treatment are the same as in cellulitis in other parts of the body. Congenital Umbilical Fistulse. — Congenital umbilical fistula? are occasionally encountered. They are of two kinds, the urinary and fecal. The former are due to the persistence of the urachus; the latter, to a failure of complete closure of the vitello-intestinal duct which may lead direct to the intestine or to a Meckel's diverticulum. As a rule, the opening is minute and only a small amount of fluid exudes. The character of the fluid is often apparent by the odor, or it can be determined by chemical or microscopic examination. Treatment. — The treatment of these cases should aim to effect a permanent closure of the opening. This sometimes may be accom- plished by cauterization, which destroys the mucous membrane and leaves a scar which subsequently contracts and obliterates the canal. If this fails, a fine probe should be introduced into the canal, an incision made in the direction of the probe, the duct isolated and ligated with fine chromicized catgut, and the distal end cut off and cauterized, after which the cutaneous wound should be disinfected and closed with sutures. When the fistula communicates with the lumen of a Meckel's diverticulum, laparotomy and removal of the diverticulum are indicated. TUMORS OF THE ABDOMINAL WALL. Primary malignant tumors of the abdominal wall are rare. Epi- thelioma and sarcoma have been reported, the former generally occurring at the umbilicus, the latter growing from the muscular or fascial planes. Of the benign tumors, which are of more frequent occurrence, lipomata are perhaps the commonest, the others in the order of frequency being angiomata, fibroneuromata, dermoid, and other cysts. The diagnosis and treatment of these tumors of the abdominal wall present no special features, and differ in no respect from the diagnosis and treatment of like tumors in other parts. 508 DISEASES OF THE ABDOMEN Johannes Miiller in 1838 described a tumor of the abdominal wall which he termed a desmoid, and which may be said to occupy a position between the malignant and innocent growths. It is a "cellular fibroma," which occurs mostly in women who have borne children, and generally is located in the rectus muscle. It is round, ovoid, or oblong in shape; if often arises from the fibrous sheath, and occasion- ally has bony attachments. It grows rapidly at times and may reach the size of an orange or cocoanut. According to Pfeifl'er 33 per cent, recur after operation. The treatment should be early radical removal. DISEASES OF THE PERITONEUM. The peritoneum lines the abdominal cavity, and is the largest serous sac in the body. Its area of surface is nearly equal to that of the integument. Its surfaces, lined with a single layer of endothe- lium, are everywhere in contact, a capillary space existing between them normally with only enough fluid for purposes of lubrication. It closely invests the abdominal parietes and the intra-abdominal organs over which it is reflected, forming a complete investment for some and a partial investment for others. Certain parts of the abdominal cavity are separated from the rest in a measure by its folds, a fact which has its practical surgical significance, as peritonitis occurring in those sites, is more apt to become localized and prevented from spreading to other parts of the peritoneal cavity, as the lesser omental cavity, the subphrenic space. The absorptive power of the peritoneum is very great : large quantities of fluids can be taken up with great rapidity. It is known that con- siderable quantities of bacteria or toxic materials can be obsorbed and taken care of by the normal peritoneum without causing peri- tonitis. It has also been shown that virulent bacteria introduced into the peritoneal cavity of animals for experimental purposes can be demonstrated in the blood stream within a very few moments, showing the probability that in more acute and fatal forms of peritoneal sepsis, death is due rather to a general bacteriemia and septicemia, than to peritoneal inflammation. It has been shown that this absorptive power is greater in the upper abdominal cavity in the region of the diaphragm than in the lower abdomen. The parietal peritoneum is abundantly supplied with sensory nerve endings, which are absent in the visceral peritoneum. For this reason, tenderness and muscular rigidity are very early signs when an inflam- matory process first involves structures in contact with the anterior parietes, but are later in developing when the initial inflammation is deep-seated and separated from the anterior parietes by coils of intestines, or viscera not yet involved. The reparative power of the peritoneum is not exceeded by that of any structure in the body; it is peculiar in that the condition most DISEASES OF THE PERITONEUM 509 favorable for the rapid repair of wounds is not the accurate apposi- tion of cut surfaces, but rather contact of free endothelial surfaces which have been irritated or traumatized, or merely held firmly in contact by sutures or other means. To counteract the influence of irritants of various sorts, there is a rapid exudation of fibrinous lymph which glues the surfaces together. ^Yhen the irritation is slight, and of short duration, this may be completely absorbed, leaving the sur- faces again normal. If of a more marked degree, or of longer dura- tion, permanent adhesions may result. It is by this process that protective adhesions form around a focus of infection and tend to localize the area of inflammation. Acute Peritonitis. — This may occur as a non-infective, or an infective process. Non-Infective Peritonitis. — Non-infective peritonitis may be caused by effusions of blood, as of an ectopic pregnancy, ruptured spleen or liver; by the escape of sterile contents of intra-abdominal cysts; by non-infective bile, as from contact in the course of operations on the biliary passages; by trauma, as in severe contusions of the abdomen without rupture of viscera; by trauma in the course of operations; by contact with chemical irritants, as strong antiseptic solutions; by the presence of aseptic foreign bodies in the peritoneal cavity, such as gauze pads, instruments, etc. The exudate is serous or fibrinous, and may be completely ab- sorbed when the source of irritation is removed. It may result in the formation of temporary or permanent adhesions; or, it may become infected from the passage of bacteria through the intestinal walls, or from the blood stream, and the character of the process thus changed to an infective type; thus aseptic foreign bodies (gauze pads) may become encysted by adhesions and remain sterile; or, infection may occur with the formation of abscesses, sinuses, or fistula 3 . A certain amount of non-infective peritonitis resulting from the process of handling peritoneal surfaces during abdominal operations probably occurs after every abdominal operation, and is generally a negligible factor in convalescence. Severe manipulation, rough use of gauze sponges, or contact with strong chemical irritants may, however, result in paralysis of the intestines, formation of adhesions, and be a serious factor in the postoperative course. It is also of importance from the fact that traumatized or irritated peritoneum is less able to resist bacterial infection, and thus serious postoperative infective peritonitis may follow operations involving much peritoneal trauma with relatively slight bacterial contamination, when with less trauma, a similar amount of contamination could be easily cared for by absorption without untoward result. Again, when associated with intestinal paralysis, due to much handling of the intestine, the change to a serious infective type of postoperative peritonitis, may be caused by the passage of germs through the damaged intestinal wall. 510 DISEASES OF THE ABDOMEN Infective Peritonitis. — Etiology. — Infective peritonitis is due to bacterial infection of the peritoneal cavity, and may be localized, spreading, or general. It may be due to wounds of the abdominal parietes, or to penetrating wounds involving intra-abdominal viscera; to rupture of intra-abdominal viscera from crushing injuries, as the intestine or bladder; to perforating lesions of intra-abdominal organs, the vermiform appendix being by far the most frequent offender; perforated ulcers of the stomach or duodenum; perforated typhoid ulcers; perforated ulcers of the cecum or colon; diverticulitis of sigmoid with perforation; localized gangrenous processes from strangulation, as in hernia?; from mesenteric thrombosis, or intussus- ception; from gangrene of the gall-bladder, or ulceration caused by foreign bodies. Peritonitis may occur with any of the above lesions by extension of the infection through the inflamed or necrotic wall of the viscus without actual perforation. It may be due to suppurative lesions of adjacent organs or structures, such as infective lesions of the liver, gall-bladder, pancreas, spleen, kidney, Fallopian tubes, ovaries or uterus; retroperitoneal infective processes, or even to suppurative processes in the thorax. Of the bacteria causing peritonitis, the streptococcus pyogenes is most frequently responsible for the virulent types. Staphylococcus pyogenes aureus; colon bacillus which is present in all cases due to perforative lesions of the gastro-intestinal tract, but often associated with other organisms; the gonococcus; pneumococcus; the typhoid bacillus; occasionally the bacillus pyocyaneous; and also the tubercle bacillus which produces the particular form of peritonitis to be described later. Pathology. — Infective peritonitis may be localized, diffuse, or general, depending upon the virulence of the infective organism, the amount of infective material introduced, the rapidity of its introduction, the location of the infection, and the degree of resistance of the individual. When the infective material is small in amount, of moderate viru- lence, and not introduced too rapidly, localized peritonitis results. The protective power of the peritoneum is stimulated, fibrinous exudate is thrown out in abundance around the infected focus, the omentum finds its way at once to the point of irritation, the intestinal coils adhere and aid in forming a barrier. Examples of this type are of the commonest occurrence, as in small perforations of the appendix which contain little infective material, a little leakage, rapid forma- tion of protective adhesions which soon occlude the minute perforation, and at some future operation the evidence of the process is found only in the remaining adhesions. A similar process may occur with gastric or duodenal ulcer. The next step in the process is when the infection is a degree more virulent, the infective material more abundant, or the resistance less effective. Adhesions form but are forced back by the enlarging DISEASES OF THE PERITONEUM 511 abscess over a wider and wider area until relief is obtained by incision, or there is a rupture of the abscess into the intestine, or through the wall of the adhesions into the free peritoneal cavity, causing diffuse peritonitis. Diffuse Peritonitis. — Diffuse peritonitis is a term rather loosely applied to cases of varying extent, which do not involve the entire abdominal cavity. Always serious, it varies greatly in its virulence and fatality, in the balance between the intensity of the infection and the resistance of the individual. The exudate may vary in character in different parts of the affected area. At the site of the focus of infection, there may be true abscess, often with fecal odor, partly or completely surrounded by adhesions; in the next zone purulent exudate with flakes of fibrin without offen- sive odor, partly limited by adhesions; still further away, slightly cloudy serous effusion, cultures from which are often sterile. A variety of diffuse peritonitis known as "progressive fibrino- purulent peritonitis" is characterized by collections of pus almost completely separated by massive fibrinous exudate, adherent coils of intestine and omentum. This type has a tendency to spread from one part of the abdomen to another, and is a serious and often fatal form of peritonitis, but may be controlled by evacuation and drainage of the separate collections of pus as soon as they can be recognized. In the virulent forms of acute peritoneal sepsis, due to gangrenous appendicitis, gangrene of the gall-bladder, or seen in the postoperative type, the surface of the peritoneum loses its lustre, becomes slightly congested, but there may be little or no serous or fibrinous exudate. In the fulminating cases, resulting in death within twenty-four or forty-eight hours, the infection is overwhelming from the beginning and the resisting powers of the peritoneum are paralyzed, the whole picture being one of a violent general toxemia rather than a peritoneal inflammation. Peritonitis arising from inflammation of the uterus or Fallopian tubes, if of a puerperal origin, or following uterine instrumentation, is usually due to a streptococcus, is of a high degree of virulence, and more the type of a septicemia than of a mere peritoneal inflammation. If due to a gonococcus, the inflammatory reaction and constitutional symptoms, are often violent at the onset, but soon become subacute, or chronic; the amount of fibrinous exudate is generally great, and resulting adhesions extensive, but confined to the pelvis and lower abdomen. Abscess formation may or may not take place. The process is rarely generalized. Symptoms. — Symptoms of peritonitis vary in severity and in the preponderance of certain features, according to the type of the process, the causative lesion, the age and resistance of the patient, and the virulence of the infection. Thus, in acute peritoneal sepsis, the symptoms of severe septic intoxication often overshadow com- pletely the local symptoms. Certain cardinal symptoms, however, are 512 DISEASES OF THE ABDOMEN present in nearly all cases. In the order of their development and diagnostic importance we may consider the following: pain, vomiting, tenderness, muscular rigidity, elevation of pulse rate, and generally of temperature, leukocytosis, and some degree of prostration. Added to these, as the disease progresses, may be abdominal distension, hiccough, restlessness and anxiety, or cerebral symptoms; signs of free peritoneal fluid; and, if the process becomes localized, or partly so, tumor, caused by inflammatory exudate or abscess. Pain is the initial symptom, and is constant. In perforative lesions it may be of great violence, and accompanied by prostration or collapse. Its site at the onset often is indicative of the cause of the peritonitis. The initial pain, however, is not always directly at the site of the causative lesion, as in perforative appendicitis, the initial pain may be in the epigastrium, or at the navel, shifting later to the right iliac- fossa. The pain of peritonitis in many instances is preceded by the pain of the causative lesion, but generally, the change in character and severity with the onset of peritonitis is abrupt and not difficult to recognize. With severe peritoneal sepsis, pain may be slight, or absent. Vomiting, as a rule, quickly follows the onset of the pain. It is first of stomach contents; later, if persistent, of watery bile-tinged fluid; of brownish-colored material; or, finally, of intestinal contents. In the mild and localized cases, it may be present only at the onset and soon ceases. In severe progressive cases, it becomes almost constant, a regurgitation, or overflow, with little apparent effort. Only in exceptional, or very mild cases, is vomiting absent. Tenderness on pressure quickly follows the onset of pain; and if the process involves the parietal peritoneum, it is accompanied by muscular rigidity. Tenderness is at first limited at the site of the initial lesion, spreading from there to other portions of the abdomen. With muscular rigidity, it is the most valuable diagnostic sign, and the most reliable indicator of the site of the causative lesion. Increase in an area of tenderness and rigidity, means diffusion of the peritonitis. The most extreme degree of rigidity is seen with perforative gastric or duodenal ulcer, and is described as "board-like." Rigidity, even of a slight degree, over the appendix, gall-bladder, duodenum or stomach, sigmoid, or ileum in typhoid, is a warning of beginning peritonitis, and if detected early, may allow of surgical intervention before actual perforation or serious spreading peritonitis supervenes. Rigidity may be slight, or absent, in the fulminating forms of peritonea] sepsis; in some rapidly fatal cases of postoperative perito- nitis; and occasionally in wide-spread peritonitis with a purulent exudate of mild virulence. The [jtilse rate rapidly rises in peritonitis; the quality, at first good, as the peritonitis progresses, becomes weak, thready, and compressible. The change in rate and character of the pulse is a DISEASES OF THE PERITONEUM 513 much more constant and valuable diagnostic sign than a change in the temperature. It is important to note the relative rate, progressive increase in the septic cases being significant. Elevation of temperature, as a rule, accompanies the onset of perito- nitis. There is no typical temperature curve, however, and the absence of fever, or a very slight rise in temperature counts little against the diagnosis of peritonitis, if other, more important signs are present. The subnormal temperature, when associated with a rapid, weak pulse and some degree of cyanosis, is of grave significance. Chills are rarely present during the course of peritonitis. They occasionally occur at the onset, especially if some gangrenous process is present. Leukocytosis is regularly present, and with the advance of the process, rises. The actual count varies much in different cases, and is of less value than the relative amount in several repeated examinations. Prostration may be mild, or, in severe forms extreme from the onset, especially in the larger perforative lesions, or in the acute forms of peritoneal sepsis. Distension, or meteorism, is present to a greater or less degree in all cases, and in considerable extent. It may become so great as to embarrass respiration by pressure on the diaphragm. It is greatly increased by the taking of food, or by cathartics given in an early stage of a spreading peritonitis. It is due to decomposition and fermentation of intestinal contents, and to paralysis of intestinal muscle. Hiccough is an occasional symptom, not present in all cases, but may be extremely troublesome and persistent. In advanced cases the peritonitis facies is quite characteristic. The face pinched and drawn, will be blue, the teeth dry and covered with sordes; tongue coated and tremulous. Great restlessness and anxiety, with the mind alert and active, is the characteristic of severe peritonitis up to the very late stages, when delirium, stupor, or coma may supervene. One frequently sees, however, the mental condition clear and active up to the very hour of death, adding greatl} r to the distress of the condition. The characteristic attitude of the patient is the dorsal position with the knees drawn up, to relieve tension on the abdominal and iliac and psoas muscles. Signs of free peritoneal fluid are often absent, and of little value in the diagnosis. Shifting dulness in the flank may indicate its presence. Cyanosis., with cool, clammy skin, is a late symptom, due to circula- tory failure, and to lack of oxygenation through the shallow respiration. Tumor, or mass indicates localization of the process, partial or complete, and is due to agglutination of intestinal coils or omentum, with inflammatory exudate, or the actual presence of pus. Diagnosis. — Usually the diagnosis of peritonitis is easily made from the signs and symptoms already described. Occasionally the various 33 514 DISEASES OF THE ABDOMEN forms of colic may cause confusion in the early stage, as, intestinal, nephritic, gallstone, or lead colic; also acute gastro-enteritis, or intes- tinal obstruction. Acute pancreatitis may simulate the violent forms of peritonitis due to perforative lesions of the upper abdomen. Acute septic infarcts of the kidney may be mistaken for peritonitis due to an acute appendicitis. Symptoms of the various causative lesions already enumerated may merge into those of a resultant peritonitis, the onset of which, however, is generally well defined by the abrupt change in character or intensity of the symptoms. Course. — The course of peritonitis varies greatly, as has already been indicated in discussing the symptoms. Rapid forms of peri- toneal sepsis may terminate fatally within twenty-four to forty-eight hours. The more usual course in the unfavorable cases is for the symp- toms to increase gradually in severity for four to six days before resulting fatally. In the progressive fibropurulent form the course may be still slower. Cases terminating in localization show improvement as a rule in from two to four days. Prognosis. — The prognosis in the local forms is generally favorable if proper surgical treatment is instituted, or if the type is one which may go on to spontaneous recovery. In the diffuse, advancing forms, much depends upon the balance between the severity of the infection and the resistance of the individual; and much, also, upon the intelli- gence with which treatment is directed. Generalized peritonitis, or that involving all portions of the perito- neal cavity, is usually fatal, though occasionally recovery may occur, especially in children. Pneumococcus peritonitis is a rare form which may be attended with, or follow pneumonia, or may occur independently. It has been most frequently observed in female children, and is thought to be an hemotogenous infection, the germs reaching the peritoneum directly from the blood stream, or possibly sometimes by way of the lymphatics through the diaphragm. It is usually extensive or general in its dis- tribution. The exudate is purulent, odorless, often containing clots of fibrin. The degree of septic intoxication is as a rule less marked than in peritonitis due to gangrenous or perforative lesions. Complications. — Complications of peritonitis, as secondary abscess, particularly subphrenic abscess, are really variations in its course and localization; other complications and sequelae depend largely upon adhesion formation and its resulting pain or interference with the function of the intestine, stomach or biliary ducts. Subphrenic abscess is a collection of pus between the upper surface of the liver and the diaphragm, more often to the right than to the left of the suspensory ligament. It may be simply the extension of a progressive fibrino-purulent peritonitis, or secondary to suppurative appendicitis, in which case the extension may ascend directly up the DISEASES OF THE PERITONEUM 515 colonic gutter, or be carried by the retroperitoneal lymphatics. It may be due to infective lesions of the liver or gall-bladder, to perfora- tion of the duodenum, or suppurative lesions of the right kidney; or, rarely, to perforation of the diaphragm by an empyema. Intestinal saphrophites occasionally are present, especially when the abscess is secondary to intestinal lesions, giving a foul odor to the exudate and quite frequently causing the formation of ga> in the abscess. The symptoms and signs of subphrenic abscess in a typical case are quite characteristic: Persistent and slowly rising fever, with the constitutional signs of unrelieved sepsis. Some degree of immobility of the costal arch with later bulging and tenderness on pressure over the lower rib^ on the affected side; increase in the area of liver dulness upward, with an arched upper limit to the dull area, sometimes dis- placement downward of the liver margin. Occasionally, when gas is present, tympanitic resonance and succussion. Fluid in the pleural cavity may develop secondarily and confuse the signs, and differentiation must be made from a localized empyema. Exploratory puncture should be performed to confirm the diagnosis. Treatment consists in evacuation and drainage, sometimes possible at the costal margin below the pleura, often best made posteriorly at about the tenth space, transpleural, in one or two stages, as con- ditions seem to indicate. Treatment of Peritonitis. — First, and most important, is the pre- ventive treatment. Early recognition of the various causative lesions, and prompt surgical relief of the same. As this principle is recognized more and more, for example, in diseases of the appendix, gall-bladder, stomach, and duodenum, cases of serious peritonitis become fewer and the mortality from this cause greatly diminished. Second, inhibitive treatment, including the various non-operative means employed to limit the extent of the peritonitis, to favor its localization, or to change a diffuse spreading type to a localized form; and the measures employed to increase the general response of the patient. These measures consist in prohibition of food or fluids by the stomach, or catharsis in the earlier stages; gastric lavage to check vomiting; salt solution by the rectum to replace the loss in body fluids; ice-bags or cool applications externally; and sedatives for the pain, used sparingly, and not at all at the onset until the diag- nosis has been made, on account of the great danger of masking the symptoms, and thereby underestimating the gravity of the condition. Third, operative treatment, which consists of the removal of the existing cause when possible; removal of purulent exudate and pro- vision for drainage of areas in which purulent exudate is likely to con- tinue to be formed. The older methods of operative treatment, with wide incisions, much sponging and trauma of peritoneal surfaces and handling of intestinal coils in the effort to cleanse the infected areas, were attended with high mortality. The whole recent technic has as 516 DISEASES OF THE ABDOMEN its basis a minimum of trauma, a minimum exposure of intra-abdominal contents, removal of purulent exudates by the quickest and easiest methods, relatively small incision, quick operation and proper drain- age, the latter not to be the huge gauze packs formerly employed. Some difference of opinion exists as to the best method of removing purulent exudate. Of the newer methods, some form of suction apparatus is probably the best. Irrigation, with large quantities of salt solution through the Blake double tube in cases of diffuse peritonitis, has been widely used, and with excellent result. Simple evacuation of pus with gentle sponging, is often sufficient in the localized cases and those of limited extent. The after-treatment is practically a repetition of the treatment enumerated under the head of "Inhibitive Treatment." Measures tending to prevent peristalsis, to prevent vomiting, to supply the necessary fluids by the rectum, and thus to conserve the natural resistance and favor localization of this process to the region of the operative field; saline solution by hypodermoclysis or intravenous infusion may be necessary if saline by the rectum is not well borne. Vomiting is best controlled by lavage; distension by rectal tube, irrigations or enemata. The Fowler position (sitting almost upright in bed) adds to the comfort and safety of the patient. Opiates should be given sparingly for the relief of pain. Tuberculous Peritonitis. — Tuberculous peritonitis may be primary or secondary to disease of the intestine, Fallopian tube, retroperitoneal lymph nodes, or to mor,e distant tuberculous lesions. It may occur at any period of life, but is most common in young adults. It occurs in two types: First, the ascitic form, with free accumulation of fluid, and numerous miliary tubercles scattered over both visceral and parietal peritoneum. The omentum is generally thickened and rolled up as a transverse mass across the abdomen. Intestinal coils may mat together and form palpable tumors. The accumulation of fluid is usually general, simulating the ascites of cirrhosis. Second, the caseating form in which there is much matting together of intra-abdominal contents about the adhesions and masses of tuber- culous tissue without fluid. This is the less common form. Symptoms. — The symptoms of tuberculous peritonitis are exceed- ingly variable. In the ascitic variety the only symptoms may be a gradual depression of health, and the slow development of ascites. In other cases digestive disturbances may be present, with attacks of colic and constipation, alternating with diarrhea resulting in wasting and progressive asthenia. Fever may be present in the later stages but often is absent early in the disease. Leukocytosis is absent. Tenderness and muscular rigidity are slight, or absent, as a rule. Signs of free peritoneal fluid are sometimes the first indication of the presence of the disease. In the caseating form, in addition to the above symptoms, one or DISEASES OF THE PERITONEUM 517 more irregular tumors are detected in the abdomen. These are at first movable but later become fixed and eventually large masses can be felt which resemble malignant disease. Areas of fluctuation some- times may be detected and muscular rigidity often is present. The association of this disease with pulmonary tuberculosis or tuberculosis in other organs, is frequent, and in the later stages is the rule. Diagnosis. — The diagnosis of tuberculous peritonitis is not always easy. The ascitic variety may be mistaken for ascites due to cirrhosis of the liver, or to ovarian, parovarian, or other cysts, or ascites due to peritoneal carcinomatosis, or to papillomatous ovarian neoplasms. From cirrhosis it is distinguished by the absence of other signs of cirrhosis, by the presence of one or more intra-abdominal nodules; by its slow development, and by the presence of other tuberculous deposits. From a la'rge abdominal cyst it is to be distinguished by the fact that there is flatness in the flanks while the patient rests on the back, with resonance over the centre of the abdomen, and the flatness can be made to change its position by moving the patient on the side. In large cysts of the abdomen, on the other hand, the centre of the abdomen presents an area of flatness with resonance in the flanks, from crowding of the intestines into the lateral portions of the cavity. The caseating variety is to be differentiated from new growths of the abdominal viscera by the facts that fever usually is present, and that the tumors are, as a rule, multiple; from intra-abdominal abscesses tuberculous peritonitis is distinguished by the absence of leukocytosis. When the diagnosis is in doubt, the tuberculin test, inoculation of a guinea-pig by the fluid, or an exploratory laparotomy, may be employed. Treatment. — Experience has abundantly proved that in cases of the ascitic variety of tuberculous peritonitis, laparotomy with evacua- tion of the fluid and subsequent suture of the wound with or without drainage, results in cure of the disease in about 50 per cent, of the cases. The same treatment applied to the caseating form of the disease, with a limited separation of adhesions and the evacuation of abscesses if present, results in marked improvement or recovery in a smaller number of instances. The reason for this is not definitely known. Hildebrandt, from a series of animal experiments, concluded that the opening of the abdomen and admission of air resulted in a more or less prolonged hyperemia, which exerted a curative effect upon the disease. Other experimenters have advanced the hypothesis that the operation caused the death of numerous bacilli, and that these produced an antitoxin which, by absorption, acted in the same manner as Koch's tuberculin and other similar preparations. Yeo and other medical observers have reported large series of cases treated by non-surgical measures which also showed a recovery rate of nearly or quite 50 per cent. It is probable, as pointed out by Ochsner, that the majority of the cases treated surgically were more advanced, and had resisted treatment by purely hygienic and medical 518 DISEASES OF THE ABDOMEN measures, and, therefore, the two classes could not with propriety be compared. The consensus of opinion at present is that all early cases should have the advantage of careful hygienic and medical treatment for a reasonable period. If not improved, they should be treated by laparotomy. William J. Mayo strongly recommends a search for and removal of the primary focus, which, in a large number of cases, will be found in the Fallopian tubes or appendix. A failure to remove this, in his opinion, is responsible for many cases of relapse. Chronic Peritonitis. — This term covers a variety of conditions, most of which are of purely medical interest. Among these may be men- tioned : a general thickening of the membrane, accompanied by ascites and often associated with cirrhosis of the liver; localized thickening and adhesions remotely associated with the septic forms of peritonitis; and the general adhesive variety of tuberculous peritonitis which is the result of recovery from either of the two acuter forms of the disease. They are of surgical interest only when they give rise to intestinal obstruction, and will be considered under that head. Actinomycosis of the Peritoneum. — Actinomycosis of the peri- toneum may follow extension of the process from the stomach, cecum, appendix, or from a retroperitoneal or pelvic focus. The disease produces a thickening of the peritoneum with suppuration similar to the caseating form of tuberculous peritonitis. Sooner or later adjacent structures are invaded and the disease slowly advances to other organs and the abdominal wall. When the latter is involved, there occurs a brawny induration, with a bluish-purple discoloration of the skin, which gradually fades in the periphery of the lesion to a dull slate color. Fistula? form and are surrounded by granulomatous tissue, making a characteristic cutaneous lesion. DISEASES OF THE STOMACH. Foreign Bodies. — Foreign bodies which have been swallowed may lodge in the stomach or in any portion of the intestinal tube. In general it may be stated that any body which passes the esophagus will in all probability pass through the stomach and bowel, and event- ually be expelled by natural processes. The swallowing of a foreign body may be accidental or intentional ; the former is observed mostly in children; the latter, in the insane. A number of cases are on record where, on operation, the stomach was found to contain scores of irri- tating foreign substances as nails, tacks, fragments of broken glass, pins, pocket-knives, etc. Hairballs are not infrequently formed in the stomach by the matting together of numerous small masses of hair or wool which have been swallowed. Enteroliths are concretions formed in the intestinal canal by the deposition of salts around some foreign body as a gallstone or hard fecal concretion. They may reach an enormous size. DISEASES OF THE STOMACH 519 Symptoms. — The presence of a foreign body in the stomach may produce no symptoms whatever; or it may give rise to pain, nausea, and vomiting. These symptoms are apt to come on in paroxysms, and closely resemble the gastric crises of locomotor ataxia. If the bod}' is lodged in the small intestine near the stomach, the symptoms are similar to those of a foreign body in the stomach. The pain, however, may be localized somewhat lower. If the body lies lower down in the small intestine or in the colon, there will be more or less constant localized pain, with or without symptoms of intestinal obstruction. Coins and other metallic bodies often may be located by the .r-rays. The retention of Murphy buttons after operation upon the intestines is of fairly frequent occurrence. As a rule, they produce Fig. 267. — Acute dilatation of stomach. (Conner.) no symptoms and the patients are unaware of their presence. Occa- sionally symptoms are produced which necessitate their removal. Treatment. — The treatment of irritating foreign bodies in the stomach or intestine consists in their removal by gastrotomy or enterotomy. Acute Gastric Dilatation, or Gastromesenteric Ileus. — Hilton Fagge, in 1873, first described the symptoms of acute gastric dilatation, but it is only within recent years that the condition has been recognized as a postoperative complication. The chief etiologic factors are a rapid dilatation of the stomach with increased secretion, later the pressure of the gastric tumor on the movable small intestines, forcing them downward, and producing 520 DISEASES OF THE ABDOMEN thereby tension on the root of the mesentery, which in turn compresses the third portion of the duodenum against the spine and causes more or less occlusion. Kinking of the duodenum from prolapse of the distended stomach may also be a factor of importance. As a result of the duodenal obstruction the stomach becomes enor- mously distended with fluid and gas, and may occupy the greater part of the abdominal cavity (Fig. 267). The primary dilatation of the stomach is probably caused by a muscular paresis from toxemia, due to acute or chronic disease, or from surgical operation or shock. The exciting cause may be an indiscretion in diet, or the ingestion of food or water too soon after operation, before the stomach wall has had time to regain its muscular tone. Conner states that 41 per cent, of the recorded cases followed operation. Symptoms. — The symptoms of the condition in the order of their importance are: vomiting, prostration, and pain; the signs: distention of the abdomen, beginning in the epigastric and left hypochondriac regions and extending downward and to the right, tenderness over the region of the distension, thirst, hiccough, progressive weakness and obstinate constipation. The occurrence after operation of persistent vomiting, a progressive distension of the abdomen from above downward, and a rapidly advancing prostration without fever or other signs of peritonitis, should at once awaken the suspicion of gastric dilatation. Diagnosis. — The diagnosis can be established by the passage of the stomach tube and the withdrawal of large quantities of gas and a cloudy, greenish fluid, with a sickening foul odor, but not feculent in character. If unrecognized or untreated the progress is rapid toward a serious and often fatal exhaustion. Treatment. — The treatment should consist in regular gastric lavage, hot stupes to the abdomen, and the hypodermic use of strychnine in large doses. Gastric and Duodenal Ulcer. — Gastric and duodenal ulcer have many pathological and clinical features in common. Both may be described as chronic ulcerating lesions which may involve the mucous membrane, the submucous or muscular coats, or extend through to the peritoneum; both have for their seat of election tissues in the immediate region of the pyloric sphincter; both give rise to a chronic digestive disorder of middle life, characterized by periodic attacks of epigastric pain, excessive gas and occasional vomiting; both may be complicated by severe hemorrhage, perforation or stenosis. On the other hand, carcinoma which frequently results from the degenera- tion of a gastric ulcer seems almost never to take its origin from the duodenal lesion. Regarding frequency it may be stated that gastric and duodenal ulcer occur in about 2 per cent, of all adult subjects. While it is GASTRIC ULCER 521 undoubtedly true that spontaneous cure occurs in a large number of instances, in the majority of cases, the disease is progressive, and leads to chronic invalidism, or death from one of the terminal complications. GASTRIC ULCER. The disease occurs in three forms: First, the mucous erosion or minute bleeding point, with difficulty seen at autopsy or at operation unless actively bleeding. It is often multiple and gives rise to copious hemorrhages, but rarely to aggravated symptoms of dyspepsia. Second, the acute non-indurated, round, or peptic ulcer, most fre- quently observed in anemic young women between eighteen and thirty years of age. This often bleeds copiously, gives rise to acute pain, pyrosis, nausea, and vomiting, and is generally associated with hyperchlorhydria. Third, the chronic indurated ulcer, involving all the coats of the viscus and often associated with a cicatrix on the peritoneal surface. This variety occurs with greater frequency in men between thirty and fifty, and is the lesion present in a large number of the patients who suffer for many years from intractable dyspepsia. Etiology. — The etiology of gastric and duodenal ulcer is still obscure, although a considerable amount of research has been and is being carried out, in the hope that when the causation of the disease can be clearly demonstrated, more rational therapeutic measures may be formulated than those at present in use. Undoubtedly autodigestion of the gastric mucous membrane, made possible by a necrosis or diminished vitality of certain limited areas of the gastric mucosa, is one of the end results of the pathologic process, but what gives rise to the necrosis or diminished resistance of the tissues has not been definitely demonstrated. Formerly the areas of low resistance were thought to be the result of trauma from masses of incompletely masticated food, or from local ischemia from thrombosis of the neighboring vessels, arterial sclerosis or profound anemia. At present there seems to be more evidence in support of the theory that the agents which give rise to this lowered resistance are toxic in origin, and have a selective action on the small masses or islands of lymphoid tissue which are scattered throughout the mucous mem- brane of the stomach, but chiefly found near the pylorus or along the lesser curvature. The effect of hemorrhagins and mucolysins of toxic origin, may also play an important part in the process, the former by causing a destruction of the endothelial lining of the terminal bloodvessels giving rise to local ecchymoses, the latter by causing an erosion of the epithelium of the mucous membrane. At any rate clinical observa- tion demonstrates that most victims of gastric and duodenal ulcer are suffering from some form of toxemia. Occasionally this may be traced to intestinal stasis, but more frequently to some sub-acute septic 522 DISEASES OF THE ABDOMEN focus, as a chronic appendix, biliary sepsis, Rigg's disease, or infection of the tonsils or one of the nasal sinuses. During a recent series of experiments Rosenow was able to produce gastric ulcer in dogs, by injecting cultures of various strains of streptococci directly into the circulation. In a few instances these organisms were demonstrated in the deeper tissues of the ulcer. If these observations can be confirmed, the etiology of gastric and duodenal ulcer will be much simplified, and in all probability, placed upon a sound bacterial basis. While the first and second varieties may give rise to severe and often fatal hemorrhage, and, while the round peptic ulcer may occa- sionally perforate, it is with the third easily recognized form that the surgeon has largely to deal. This particular type occurs much more frequently in the stomach, and is more commonly observed in men. Of the stomach ulcers 90 per cent, occur at the pylorus or along the lesser curvature. Of the latter a frequent type is the "saddle ulcer" extending from the lesser curvature downward on both the anterior and posterior surfaces of the stomach. Multiple ulcers are not infrequent, and a given ulceration may pass the pylorus and involve both the stomach and duodenal mucous membranes. Symptoms. — The symptoms of chronic indurated gastric ulcer are generally those of an obstinate dyspepsia. The typical symptoms of ulcer may for a time be preceded by those of hyperchlorhydria, acid eructations, moderate discomfort after meals, and a hungry, gone feeling at the pit of the stomach before meals, which is relieved by taking food. When open ulcer is present there is epigastric pain, which appears regularly from one-half to two hours after the ingestion of food. This pain varies from a dull feeling of weight to a severe and progressively increasing paroxysm of pain resembling gallstone colic. At the height of the paroxysm vomiting may occur, which gives prompt relief. The vomited matter is exceedingly acid and leaves a burning sensation in the throat. Acid eructations and tenderness are generally present. Gastric analysis will frequently show an increase both in the total acidity and the free hydrochloric. Anemia and loss of weight may occur from inanition, as the typical sufferer from gastric ulcer will starve himself rather than endure the pain of taking hearty food. Hemorrhage occurs in the majority of cases of ulcer. The amount is often so small as only to be detected by a careful microscopic examina- tion of the stools or delicate chemical tests (occult blood). In a fair number of the cases the bleeding is copious, evidenced by severe hematemesis and well-marked melena. In a small proportion of the patients it may be the immediate cause of death. While all of these symptoms except severe hemorrhage may occur in purely functional disorders of the stomach, the regularity of their occurrence, day after day, at a definite time after each meal; the chronicity of the disorder, and the prompt relief of a given attack following vomiting, lavage GASTRIC ULCER 523 alkalies or, to a certain extent, more food, renders the diagnosis almost certain. Another characteristic feature of gastric nicer, is the fact that remissions occur, extending over a longer or shorter interval, during which the patient may enjoy perfect and symptomless digestion. These periods of immunity frequently follow a vacation or the sudden relief of worry or exhausting mental activity. One of the most impor- tant, if not the most important advance which has occurred in the diagnosis of gastric and duodenal lesions, is the employment of serial roentgenography, which will be referred to again in the section on Cancer of the Stomach. Of the complications of gastric ulcer, severe hemorrhage occurs in about 8 per cent, of the cases. In a small proportion of these death ensues before any rational treatment can be carried out. Autopsies in these cases show, generally, erosion of the splenic artery or one of its larger branches. Gastric hemorrhage is preceded by a definite feeling of nausea. This is followed by vomiting of large quantities of fluid and clotted blood. Melena follows for several days. Over 90 per cent, of these severe hemorrhages cease spontaneously. Perforation occurs in from 12 to 20 per cent, of gastric and duodenal ulcers. In the majority of instances the perforation occurs on the anterior surface, is accompanied by extravasation of the highly acid gastric contents, and gives rise to a rapidly spreading septic peritonitis. In a small number of cases the perforation is minute and quickly sealed by a fibrinous exudate, or the peritonitis is limited by protecting adhesions. As a result of edema, the gradual development of cicatricial tissue, peritoneal bands, adhesion to other organs, pyloric stenosis occurs in a large number of these patients. This results in a gradual dilatation of the stomach, diminished motility, and fermentation, the symptoms of which will be described in the next section. Hour-glass stomach is a rare complication. Another rare complication of gastric or duodenal ulcer after gastrojejunostomy, is the formation of a peptic ulcer of the jejunum, at or just below the line of anastomosis. These ulcers rarely give rise to much pain, but often occasion repeated hemorrhages, and in rare instances perforation will occur. Prognosis. — The statistics of Greenough and Joslyn, based upon an analysis of 187 cases of gastric ulcer treated medically at the Massa- chusetts General Hospital, show that while 80 per cent, were discharged as cured and only 8 per cent, died; subsequent inquiry made several years later showed that only 40 per cent, remained well, and that 20 per cent, had died as a result of the disease. In other words, 60 per cent, of the victims of chronic gastric ulcer treated medically must look forward to death or a life of chronic invalidism. Statistics from the best modern surgical clinics show that the same class of cases treated surgically give a death rate of less than 5 per cent, and upward of 70 per cent, of permanent cures. The prognosis of primary hem- 524 DISEASES OF THE ABDOMEN atemesis is generally favorable. Repeated hemorrhages, however, constitute a bad prognostic sign. The prognosis of perforation varies with the time which has elapsed between the accident and the lap- arotomy. In cases under twelve hours the outlook is favorable; beyond that period the mortality increases with each hour of delay. It is now pretty generally admitted that gastric ulcer is one of the most, if not the most important cause of cancer, Mayo reporting that upward of 50 per cent, of gastric cancers removed at the Rochester clinic show unmistakable evidence of having developed upon ulcer. Treatment. — Gastric ulcer without pyloric stenosis or other complica- tions should be subjected to intelligent, hygienic, medical and dietetic treatment for at least six weeks. If not relieved by this treatment, or if there is a strong tendency to recurrence after a medical cure, operation should be advised. In indurated ulcer at or near the pylorus Rodman advises pylorec- tomy on account of the strong tendency of such lesions to degenerate into cancer. Under favorable conditions the mortality should not be much above that of gastroenterostomy, and the writer advises it in otherwise healthy individuals after a fair statement of the risks. Excision is to be recommended also in ulcers located at a distance from the pylorus, when the operation presents no serious technical difficul- ties. Gastro-enterostomy is, however, the operation of choice in the great majority of cases of chronic ulcer. It is also to be recommended in all cases of recurrent or persistent hemorrhage from ulcer. It should also be performed in those cases of perforation where suture of the wound causes stenosis, and in other cases where the operation is an early one, before peritonitis has had time to develop. Several theories have been advanced to explain the benefit which follows gastrojejunostomy in these cases: The first is that it results in at least a partial physiological rest of the pyloric extremity of the stomach; second, by directing the current of highly acid chyme through the stoma, it prevents the forcible contact of this irritating fluid against the open surface of the ulcer, which under normal conditions is caused by vigorous peristaltic efforts at the pyloric antrum; third, by the quick emptying of the stomach both muscular and chemical irritation is lessened; and fourth, it insures a diminution of the acidity of the stomach contents by the admixture of bile and pancreatic juice which gain entrance through the artificial opening. It is probable that all of these factors play a part in the therapeutic effect. While it has been shown that in a large number of cases of ulcer with open pylorus, the greater part of the food still passed through that opening after gastrojejunostomy has been performed, the result in the majority of these instances is satisfactory, showing that the quick emptying of the stomach and neutralization of the acid chyme were the respon- sible factors in the relief of symptoms. Other things being equal, however, the cases of pyloric ulcer with stenosis show a higher per- GASTRIC ULCER 525 centage of cures after gastrojejunostomy, than ulcers situated at a distance from the pylorus, without stenosis. Duodenal Ulcer. — Although gastric and duodenal ulcers have many features in common, a number of differences in their pathological anatomy, symptomatology, general behavior, and treatment, renders a separate consideration desirable. Duodenal ulcer is of more frequent occurrence than gastric, the pro- portion being about six duodenal to four gastric. Eighty per cent, occur in males. Nearly all (98 per cent.) occur in the first one and one- half inches of the duodenum. In a small number of instances, a duodenal ulcer may extend through the pyloric ring and involve the gastric mucosa. Duodenal ulcers practically never degenerate into carcinoma. While extensive ulcerations of the duodenal mucous membrane, associated with much infiltration and a white peritoneal scar are occasionally encountered (a type which closely resembles the chronic indurated gastric ulcer), a large number differ widely from this, in that the ulcer is small, round or oval, and associated with a limited shot-like induration, with no external scar or appearance of organic lesion. These lesions are often overlooked unless the first part of the duodenum is carefully examined and palpated between the thumb and forefinger. Codman has called attention to the fact that this type of ulcer is generally situated so close to the pyloric sphincter that its raw surface is concealed by the longitudinal folds of the duodenal mucous membrane when the pylorus is closed. When the pylorus opens for the passage of chyme into the bowel, the ulcer is exposed to the irritation of this highly acid fluid. He likens this type of ulcer to the anal fissure, which is irritated by the passage of acrid substances over its raw surface during relaxation of the sphincter. Like anal fissure also this ulcer is subject to periods of inflammation when the pain and other symptoms are all exaggerated for several days or weeks. Symptoms. — The symptoms of duodenal ulcer resemble those of gas- tric ulcer, in that the lesion gives rise to chronic dyspeptic attacks of e paroxysmal character. Pain is the most prominent and characteristic symptom. It occurs with great regularity, from two to five hours after taking food, and continues until the next meal, when it is promptly relieved. It is therefore often spoken of as "hunger pain." The pain has the same character as that of gastric ulcer. It varies from a slight sense of discomfort or weight in the epigastrium, to a severe colic. Often it is associated with gas, and occasionally sour eructations. Vom- iting is rare, but occasionally is induced for the relief it affords. The pain generally can be relieved by taking more food or bicarbonate of sodium, by vomiting or lavage. Many patients with duodenal ulcer acquire the bicarbonate of sodium habit. Others obtain relief by taking food at frequent intervals. Those who follow the latter plan, often gain in weight from the increased amount of food ingested, and, as described by Moynihan, appear "sleek and well-conditioned." 526 DISEASES OF THE ABDOMEN These patients often keep about and attend to their daily duties for many years without evidences of any serious deterioration in health, but the constantly recurring pain is apt to result in a change in dis- position, and they frequently become sullen, morose, and ill-tempered. Like the subjects of gastric ulcer, these individuals have frequent remissions in which they believe themselves to be cured. A vacation or sudden relief from work or anxiety will often result in a rapid and complete relief of all symptoms; but recurrences are common, and as a rule, these patients suffer most during the late autumn and winter months. Not infrequently all symptoms are exaggerated for a period of several days or weeks, as a result of an acute inflammation about the ulcerated area. During these periods marked tenderness is present over the duodenal region, and fever and malaise occasionally may develop. In rare instances in the indurated variety a tumor can be felt on palpation. Gastric analysis is of little value in these cases, although a moderate hyperacidity is usually present. As in gastric ulcer and cancer, serial rontgenography will often give positive evidence of duodenal ulceration or induration. It is important to bear in mind, however, that the symptoms of both gastric and duodenal ulcer may be mimiced by a purely functional disorder, caused by a reflex hyperemia or irritability of the gastric or duodenal mucosa, as a result of a chronic irritation from chole- lithiasis, a diseased appendix, or intestinal stasis. Prognosis. — In regard to prognosis it may be stated that while spontaneous cure occurs in a fair number if cases, in the majority, the tendency is toward an exceedingly chronic course, leading often to stenosis, hemorrhage, or perforation. Stenosis occurs somewhat more frequently than in gastric ulcer. The symptoms are identical with those of pyloric obstruction from any other cause. Hemorrhage is present in small quantities in most cases (occult blood). In a few the bleeding is severe, resulting in hematemesis and melena, and in rare instances, an inundating and rapidly fatal hemor- rhage may occur. In the latter cases, the pancreaticoduodenalis artery is generally found to be eroded. Perforation of a duodenal ulcer is rather more frequent than in gastric ulcer. The symptoms are the same, pain, sudden and severe; vomiting, epigastric tenderness, muscular rigidity, and later signs of a rapidly advancing peritonitis. Occasionally a duodenal perforation will result in a localized abscess from adhesion of the surrounding tissues. Not infrequently the early symptoms of a duodenal perforation may resemble those of an acute fulminating appendicitis. Codman has recently stated that in a large series of cases admitted to the Massachusetts General Hospital with a diagnosis of acute appendicitis, one in sixteen proved on operation to be duodenal perforation. Treatment. — All duodenal ulcers resisting a reasonable trial of hygiene, dietetic, and medical measures, should be treated surgically. GASTRIC ULCER 527 Small ulcers without stenosis should he treated by excision if readily accessible and the operation can be accomplished without producing stenosis. This will rarely be found to be possible or practicable. Occasionally small ulcers situated on the anterior wall with moderate stenosis can be excised in performing a Finney operation for pyloro- plasty. In the great majority of cases, gastrojejunostomy is the operation of choice, and in the majority of instances will bring about a cure. In ulcers with severe bleeding, in addition to the gastro- enterostomy, pyloric closure should be effected by ligation with a strip of fibrous tissue dissected from the rectus sheath, or by means of an aluminum band passed around the pylorus and tightly rolled with the fingers so as to obliterate the lumen without devitalizing the tissues. The infolding of duodenal ulcers as a routine measure by means of Lembert sutures is practiced by a number of surgeons, in addition to the gastroenterostomy ; but the author's results in these cases have been so satisfactory without this procedure, that he hesitates to advise it unless some special indication is present. The treatment of acute hemorrhage should be by rest, ice, opium, and starvation. Later rectal feeding for a time, then fluids and semi- solids by the mouth. Repeated hemorrhages call for gastroenteros- tomy, with excision of the ulcer if practicable, or closure of the pylorus. The treatment of acute perforation should be early operation, suture of the perforation, and gastroenterostomy, if the condition of the patient permits. Pyloric Stenosis. — Pyloric stenosis results from extensive ulceration and thickening, from cicatricial contraction of the orifice, from peri- pyloritis, from new growths, and from spasm. Pyloric stenosis also occurs as a congenital lesion, the cause of the obstruction in these cases being an enormous hypertrophy of the circular muscular fibres. As pyloric stenosis is most frequently associated with ulcer or car- cinoma, its early recognition is of the greatest importance. The results of pyloric obstruction are the gradual development of a dilated stomach, with or without atony of its muscular structure; retardation of the outward passage of food into the intestine; acid fermentation, and subacute gastritis. The stomach may reach an enormous size, and by its weight may drop downward when the patient is erect, so that the lesser curvature lies two or more inches below the ensiform cartilage and the greater curvature may reach the symphysis pubis (gastroptosis). Symptoms. — The symptoms of pyloric stenosis are those of a dilated stomach. There is more or less constant epigastric discomfort, with nausea, a foul tongue, and offensive breath. As only a small quantity of the food taken passes into the intestine, and as little is absorbed from the dilated stomach, the patient rapidly loses flesh and strength, the bowels are constipated, the urine scanty, the skin dry, and the mind apathetic. Vomiting is the most characteristic symptom. It 528 DISEASES OF THE ABDOMEN occurs at irregular intervals and is often copious; in severe cases two or three quarts may be expelled. The vomited matter is made up of a mixture of partly digested food suspended in a foul-smelling, dirty gray fluid containing lactic and butyric acids and other products of decomposition. It often happens that food taken a day or two previously can be recognized in the vomitus. In congenital pyloric stenosis the infant vomits frequently and shows a progressive loss of weight. A small amount of food may be retained, but if an ordinary feeding is given, it is quickly rejected. The infant apparently suffers from hunger, cries constantly, and soon presents the appearance of rapid starvation. After a feeding, visible peristaltic waves may be seen through the attenuated abdominal wall. A palpable tumor is present in about one-third of the cases. A rare form of pyloric stenosis, presumably due to spasm and associated with hypersecretion, is described as Reichmans disease, the symptoms of which are intermittent attacks of prolonged and exhausting vomiting. Diagnosis. — In the diagnosis of dilatation of the stomach the physical signs are of great importance. By inspection the outlines of the greater and lesser curvatures are often clearly projected upon the abdominal wall; and peristaltic waves may be seen passing from the fundus to the pylorus or in the reverse direction. By palpation one may elicit an abnormal splashing, of wide extent, at a time when the normal stomach should be empty. A dilated stomach when distended by gas affords a uniform elastic resistance like that of an air cushion. By percussion, in the erect posture, a line of flatness can be deter- mined, which corresponds to the level of fluid in the dependent part of the greater curvature. If now more fluid be swallowed, the upper level of flatness will be found at a higher plane. If the patient be placed in the dorsal position, or if the fluid be removed by the tube, the flatness will give place to resonance. When the stomach-tube is passed far enough to be arrested by the greater curvature the length of tube beyond the incisor teeth may reach twenty-eight inches or more; whereas the length for a normal stomach scarcely exceeds twenty-four inches. If the stomach be inflated with air, by means of the rubber bulb of an atomizer attached to the stomach tube, the examination by inspection and percussion will be greatly facilitated. The capacity of the organ may also be estimated by measuring the maximal quantity of water which can be introduced through the tube and again recovered by immediately siphoning off. Sometimes it is difficult to distinguish between dilatation of the colon and that of the stomach; but a de- cision may be reached by distending one organ with water and the other with gas. If the gastric dilatation be due to a pyloric carcinoma, which has not developed from the margins of an older ulcer, it will generally GASTRIC ULCER rr2 ( .) be Pound that free hydrochloric acid is absent or present only in traces; or that combined hydrochloric acid is present alone, while lactic acid is easily recognizable. Absence of hydrochloric acid with presence of lactic acid is not pathognomonic of carcinoma; it indicates neces- sarily only pyloric obstruction, gastric dilatation, stagnation of the stomach contents, and secretory inability; but carcinoma of the pylorus is by far the commonest cause of these associated conditions. In addition to the ordinary chemical tests, it is well to search for red blood cells with the microscope and to test for hemoglobin chemic- ally. In rare instances small particles of carcinomatous growth may be recognized by the microscope. When hydrochloric acid is absent and lactic acid present, partic- ularly in cases of carcinoma, there will often be found myriads of large, slender bacilli which stain brown with Grain's iodine solution. These " Boas-Oppler" bacilli are quite suggestive of carcinoma. Treatment. — The treatment of this condition consists in surgical procedures which enlarge the pyloric orifice, or those which, by estab- lishing a new outlet, sidetrack the obstruction and allow the organ to regain its normal tone. The former may be accomplished by pyloroplasty and pylorectomy; the latter, by gastroenterostomy, soon to be described. In congenital stenosis, gastroenterostomy is the method of choice, although the mortality is necessarily high. Bunts recently reported a series of 69 cases treated by gastroenteros- tomy with a mortality of 53 per cent. Cardiospasm. — A rare disease, probably of nervous origin, giving rise to spasmodic closure of the cardiac sphincter and retention of food in the esophagus. If the spasm continues, a compensatory hyper- trophy of the muscular coats of the esophagus occurs, which for a time prevents the development of other symptoms. Sooner or later, however, if the spasm is not relieved, dilatation of the esophagus results, with retention of food and regurgitation. Symptoms. — The symptoms are at first only a choking sensation, moderate substernal pain, and a feeling that food is arrested in the gullet. The attacks may last for several days and be relieved spon- taneously as a result of vomiting. When dilatation occurs, there is a constant substernal pain and distress with frequent regurgitation of undigested food which is alkaline in reaction. Wasting, thirst, and scanty urine are late symptoms. Treatment. — The treatment should consist in gradual dilatation by esophageal bougies when this is possible. If the bougies are arrested at the cardiac orifice, Plummer recommends the swallowing of three yards of silk thread, and later the passage of a special olive-pointed bougie w T hich is perforated at the tip for the passage of the thread. In other cases he employs an ingenious dilating rubber bag attached to the end of a bougie, which is distended by water pressure. 1 In 1 For a fuller description of these methods the reader is referred to Dr. Plummer' s excellent paper in the Journal of the American Medical Association, May 13, 1908. 34 530 DISEASES OF THE ABDOMEN neglected cases when the dilatation has become permanent and when it is impossible to introduce a bougie or other dilating instrument, esophago-gastrostomy is to be recommended. The operation is both difficult and hazardous, only a few successes have been recorded, notably one by Lambert, a report of which was published in "Surgery, Gynecology, and Obstetrics" to which the reader is referred for indi- cations and technic. Hour-glass Stomach. — Hour-glass stomach is a cicatricial contrac- tion of the walls of the stomach near its middle which divides the organ into two portions connected only by a narrow opening. This con- dition may result from the induration or healing of an extensive ulceration, from perigastric adhesions due to localized peritonitis from a small perforation, or rarely from malignant disease. If the obstruction is located near the pylorus, the symptoms may resemble those of pyloric stenosis; if near the middle of the stomach, they may differ in that the patient is able to take and retain only a small amount of food from the diminished capacity of the proximal pouch. Pain is usually present,, and malnutrition is frequently the most important symptom. In many cases a tumor can be felt which strongly resembles carcinoma. A symptom observed by the author in a well-marked case was absence of visible gastric dilatation after the introduction of air through a stomach-tube by a bulb syringe. The reason of this was apparent on opening the abdomen, when it was found that the contracting bands divided the stomach near its centre, the cardiac portion, which would chiefly be dilated by the gas, lying wholly beneath the left costal arches. Treatment. — Three methods of treating this condition have been suggested: gastroplasty, or making a longitudinal incision though the scar and uniting it transversely, thus enlarging the opening as in pyloroplasty; gastrogastrostomy, or establishing an artificial opening between the two dilated portions of the stomach ; and gastro-enteros- tomy, or uniting the jejunum with the cardiac pouch. Peripyloritis. — Peripyloritis is a condition in which there are adhe- sions between the pylorus and the anterior abdominal wall, the gall- bladder, the liver, or the colon, caused by a localized peritonitis from a perforation of the stomach or duodenum, or by extension of an inflammation from an infected gall-bladder. Symptoms. — The symptoms of peripyloritis may be those of pyloric stenosis, portal congestion, common duct obstruction, or simply localized pain. Treatment. — The treatment is by laparotomy with separation of the adhesions when this is practicable, but generally by gastrojugenostomy. TUMORS OF THE STOMACH. Carcinoma. — Next to the uterus and female breast, the stomach is the most frequent seat of carcinoma. It is responsible for about one TUMORS OF THE STOMACH 531 adult death in every sixty. It occurs more frequently in males than in females the proportion being nearly three to one. Of the pathological types of the disease, adenocarcinoma is by far the most frequent. In the Mayo clinic over 90 per cent, of specimens removed were demonstrated to be of this variety. Colloid cancer, scirrhus and epithelioma are occasionally encountered. Cancer affects the pylorus and lesser curvature in more than two-thirds of the cases. It is rarely limited to the anterior or posterior wall or the greater curvature. It is of fairly frequent occurrence at the cardiac orifice. The disease occurs late in life; an overwhelming majority developing after the fortieth year. The rate of growth varies considerably, those of the fibrous or scirrhus type advance slowly, while the more cellular varieties extend rapidly. Colloid cancer involves all the coats of the stomach at an early date, often spreads to neighboring organs and almost invariably develops multiple peritoneal metastases with ascites. Extension of the disease follows as a rule, the lymphatic channels; thus in pyloric growths and those along the lesser curvature the lymph nodes in the gastrohepatic omentum are first involved, while in growths of the greater curvature those lying between the two layers of the great omentum are enlarged. At a later period the supraclavicular and inguinal lymph nodes rarely are invaded. Direct extension of the disease to the pancreas or liver is not infrequent, and occasionally enlargement of the liver and other hepatic symptoms are noticed before the stomach lesion is recognized. Symptoms — The symptoms of gastric cancer may for a long time be extremely obscure. In not a few instances the patients present only symptoms of general ill health, with progressive anemia and loss of flesh and strength. In most cases, however, there is a history of impaired digestion, with a certain amount of pain, nausea, and vomiting. These symptoms occur more frequently after taking food, although the vomiting may be irregular or absent in cases of cancer limited to the anterior or posterior wall of the organ. In pyloric cancer the vomiting occurs one or two hours after taking food; in cancer of the cardiac orifice, at a much earlier period. Except in the very cellular varieties, hemorrhage is rarely profuse. It is frequently present, however, and appears as a black "coffee-ground" mass in the vomited material. In a fairly large number of cases, where the disease develops upon a pre-existing ulcer, the dyspeptic symptoms have existed for years, and the early history is characteristic of benign ulcer. In these cases, with or without a recent period of remission, the clinical picture gradually changes. The pain, at first acute, localized and paroxysmal, changes to a general discomfort present all the time but increased after food. Eructations change from acid to foul. Vomiting occurs less regularly and affords less relief. The appetite changes from a desire to a loathing of food. Emaciation develops more rapidly and there is a sense of bodily 532 DISEASES OF THE ABDOME.\ weakness and mental depression out of proportion to the lessened intake of food. Hemorrhage is more constant Imt often less in amount. Anemia advances and symptoms of malignant cachexia occur. Gastric analysis, in the later stages, shows an absence of free hydro- chloric acid, the presence of lactic acid, and the Boas-Oppler bacillus. The presence of a palpable tumor in the epigastric region, while frequently detectable in the later stages of the disease, is not an early sign, for the reason that the growth of the tumor is slow, and it rarely reaches a size to render its recognition easy until other symp- toms render the diagnosis certain. Moreover, only a small portion of a stomach is accessible to palpation, as two-thirds or more of this organ lies beneath the ribs on the left side. When felt, the tumor is usually hard and nodular, and moves at first with respiration. At a later period it may become fixed from adhesions to the deeper parts. Occasionally a dilated stomach may be seen on inspection, presenting peristaltic waves moving from left to right. In the later -tages of the disease there is increased pain, copious vomiting of a foul-smelling material containing food remnants, rapid wasting, progressive pros- tration, and a dry sallow skin. The stomach finally rejects all food, the patient becomes bed-ridden and dies from hemorrhage, starvation, or exhaustion from profound cachexia. Pyloric cancer produces gastric dilatation with the characteristic symptoms; cancer of the cardiac orifice produces atrophy of the stomach with enormous dilatation of the esophagus. Cancer involving the body of the organ without encroaching upon either orifice may exist for months without producing any characteristic symptoms. Diagnosis. — Viewed from a standpoint of surgical treatment, it is of the utmost importance that cancer of the stomach should be recognized at the earliest possible moment, for it is only at this period that radical treatment holds out any chance of success. The occurrence of dyspeptic symptoms with loss of flesh and anemia in an individual over forty years of age, or a distinct aggravation of a previous digestive disturbance, should always awaken the suspicion of cancer. If to this are added evidences of decreased motility of the organ, with an absence of free hydrochloric acid, exploratory laparotomy for purposes of diagnosis and treatment is justifiable if the patient wishes to avail himself of the advantages of an early radical operation. Gastric ulcer generally can be excluded by the age of the patient, the less frequent but more profuse hemorrhage, the more violent attacks of pain, hyperacidity, and the fact that the disease may last for many years without loss of weight and strength and with periods of distinct improvement in the general nutrition and anemic condition, between attacks. Atonic gastritis may show an absence of hydrochloric acid, the digestive disturbances, the loss of weight and strength, the anemia, but rarely the cachexia. Moreover, the progre>s of the disease is much slower. One of the most recent and most valuable aids to the diagnosis of gastric cancer, is the evidence furnished by the x-rays. TUMORS OF the stomach 533 Serial gastric rontgenography, after the ingestion of a bismuth meal, will often demonstrate stenosis, ulcerations, areas of infiltration, and an interruption of the normal peristaltic waxes, which, with other symptoms and signs, render an early diagnosis highly probable. Not infrequently in the presence of early and comparatively unim- portant symptoms, the rontgen rays will give positive evidence of an organic lesion, at a time when radical operation, can offer sanguine hope of a cure. 1 Prognosis. — The disease, unless radically removed at an early period, is invariably fatal, death occurring in from one to two years after the first characteristic symptoms. The interest awakened by the increasing number of cures by early and radical operative measures, which have been reported during the past few years, has led to more careful methods of examination and earlier diagnosis. As a result of this, many cases are now subjected to operation at a more favorable period, and surgeons confidently look forward to better statistics in the near future. In late cases life often can be prolonged and suffering relieved by certain palliative surgical measures, as gastrostomy and ga st ro-enterost < >m y . Treatment. — As soon as the diagnosis is established or rendered even probable, it should be decided which method of treatment is to be followed, the radical or the palliative. Radical treatment by early removal of the growth is indicated in the primary stages of the disease before wasting or marked anemia has occurred, and when there is reason to believe that the disease can be thoroughly eradicated. This, of course, can only be determined by an exploratory operation. Enlarged lymph nodes may be due to septic absorption from a malig- nant ulcer, and should not deter the surgeon from radical operation if other conditions are favorable. Carcinoma of the pylorus should be removed by pylorectomy. If the disease involves the body of the organ, gastrectomy, partial or complete, is indicated. Neither of these operations should be attempted if there is extensive lymphatic metastasis, adhesion to other organs, or if there is marked anemia or cachexia. If the palliative method of treatment is to be followed, the patient should be placed in the most favorable hygienic surroundings, should have an abundance of easily digestible, nourishing food, and if the stomach is irritable or there is evidence of diminished motility, with dilatation and fermentation, lavage should be practised daily. Gastro- enterostomy should be performed in cases of pyloric stenosis, gastros- tomy when the cardiac orifice is involved. The technic of these operations will be described in another section. Sarcoma. — Sarcoma of the stomach is a rare disease. Although, according to W. S. Fenwick, it is present in from 5 to '8 per cent, of 1 For a description of the modern method of serial rontgenography in diseases of the stomach and duodenum, the reader is referred to an article by the author and Dr. Lewis G. Cole, published in Annals of Surgery, 1915. 534 DISEASES OF THE ABDOMEN all malignant growths of the organ; the statistics of the Mayo Clinic show in their large series of cases, the ratio to be considerably below 1 per cent. Two forms are described, the small round-cell or lympho- sarcoma, a rapidly growing and exceedingly malignant tumor, and the spindle-cell variety or fibrosarcoma, a slower developing and less malignant growth. The disease occurs at an earlier age than car- cinoma, the majority of cases developing in women between thirty and forty years of age. The disease resembles carcinoma in that there are early digestive disturbances, localized pain, hemorrhage, and vomiting, with rapid loss of flesh and strength and progressive anemia. It differs from carcinoma in that the lymphosarcoma grows faster and reaches a greater size (Fig. 208); it is more movable, and is frequently Fig. 268. — Sarcoma of the stomach. associated with enlargement of the spleen, fever, general purpura, and the presence of small cutaneous sarcomatous nodules around the umbilicus. In lymphosarcoma no surgical treatment is to be recom- mended, as the growth progresses rapidly to a fatal termination, and when the disease is sufficiently far advanced to admit of a positive diagnosis it has passed beyond the possibility of surgical relief. Fibro- sarcoma should be treated in the same manner as gastric carcinoma. OPERATIONS ON THE STOMACH. Gastrotomy. — Gastrotomy consists in opening the stomach for purposes of diagnosis, the removal of a foreign body or small pedun- OPERATIONS ON THE STOMACH 535 ciliated tumor, or to effect dilatation of the pyloric orifice. A median incision should be made about four inches in length, beginning at a point about one inch below the ensiform cartilage. When the peritoneal cavity is opened, the stomach is drawn into the wound and the adjacent viscera protected by the insertion of several pads of gauze, to each of which an artery-clamp or metal ring has been attached. An incision is then made in the anterior wall of the stomach parallel with its longitudinal axis, and through this whatever further manipulations are necessary are carried out. The stomach wound is then closed by two rows of sutures, a deep one of catgut including all the coats, and a superficial row of silk sutures introduced by the Lembert or Halsted method. The abdominal wound can then be closed by layer suture, catgut for the peritoneum, chromicized catgut for the muscular and aponeurotic layers, and silk or silkworm gut for the skin, or by through-and-through silkworm-gut or silver-wire sutures. The latter method in the upper part of the abdomen is thought by many surgeons to give results equally as good as the layer suture. Digital or Instrumental Dilatation of the Pylorus. — Digital or in- strumental dilatation of the pylorus may be carried out through a gastrotomy wound by the fingers or by the use of a uterine dilator. The method is dangerous and seldom used. Pyloroplasty. — Withdraw the pylorus through a median incision in the abdominal wall. Make a longitudinal incision through the stric- ture. Convert the longitudinal incision into a transverse opening by drawing the edges of the wound widely apart by two blunt retractors, and unite by a double row of Lembert or Halsted sutures. Finney, of Baltimore, has devised a new and satisfactory method of pyloroplasty. He first frees the region of the pylorus from all adhesions, then introduces a silk retractor at the summit of the pylorus, another through the anterior wall of the stomach about three inches from the first, and a third through the anterior wall of the duodenum the same distance from the pylorus. By drawing the first retractor upward, and the two others downward, the anterior surfaces of the stomach and duodenum are brought into contact and united by a row of peritoneal sutures of silk. An inverted U-shaped incision is then made through the walls of the stomach, pylorus, and duodenum about half an inch from the line of suture. The adjacent mucous and muscular coats of the stomach and duodenum are then united by a continuous suture of catgut, and the opening closed by a row of mattress sutures, as seen in Figs. 269 and 270. This operation insures permanent patency and good drainage from the dependent position of the stomach outlet. Pylorectomy, or Partial Gastrectomy. — This operation is indicated in cases of early carcinoma of the pylorus. As Cuneo has demonstrated that the lymphatics which drain the pyloric end of the stomach follow the gastric vessels along the lesser curvature to a point where the gastric artery leaves the viscus and passes downward to the celiac 536 DISEASES OF THE ABDOMEX axis, and that the lymph vessels of the greater curvature pass toward the pylorus from a point about five inches to the left of the duodenal Fig. 269. — Finney's operation: position of parts. Fig. 270. — Finney's operation: sutures in place. junction, it is evident that to remove these and their associated nodes the line of incision through the body of the stomach must OPERATIONS ON THE STOMACH 537 be an oblique one from the junction of the gastric artery to the lesser curvature, downward to a point about five inches from the pylorus on the greater curvature. It will thus be seen that the older methods of pylorectomy advised by Billroth and Kocher were inadequate, in that they removed too little of the stomach wall. The technic of the Mayo operation based upon these observations is as follows: Fig. 271. — Pylorectomy. (Mayo.) A generous median incision is made over the gastric area and the pyloric end of the stomach withdrawn. Four ligatures are next placed on the main arteries— one on the gastric as it joints the lesser curvature, one on the pyloric, and two on the gastric epiploica dextra at the points of excision. The greater and lesser omenta are then ligated and divided some distance from the stomach, so as to leave the lymph nodes and vessels attached to the portion to be removed. 538 DISEASES OF THE ABDOMEN The peritoneum is then protected by gauze pads, the duodenum clamped by two long-bladed forceps, divided, and the cut edges disinfected. The cluodenal orifice is next closed by a purse-string suture of chromic catgut. Two other clamps are then placed across the body of the stomach in the line indicated above and the tissues divided between them. After disinfecting the wound edges, the gastric opening is closed with two layers of sutures and a gastro- enterostomy performed (Figs. 271 and 272). WIII.A.n J Mayo. Fig. 272. — Pylorectomy. (Mayo.) Gastrectomy. — This operation, which consists in removal of the greater part of the stomach, may rarely be indicated for carcinoma involving the body of the organ. The method is exactly the same as in pylorectomy, except that a larger area is removed. It will rarely be possible to unite the duodenum with the cardiac remnant of the organ, and resort must be had to a union of the jejunum with the esophageal extremity. OPERATIONS ON THE STOMACH 539 Gastrostomy. — The following method, which is a slight modification of Kader's procedure, is the simplest and safest method of gastros- tomy, and has the advantage of a valve action which prevents leakage and insures rapid spontaneous closure of the wound when the necessity for the fistula has passed. Through a vertical abdominal incision just to the left of the median line the anterior wall of the stomach is drawn into the wound and held by clamps or a provisional suture. Two circular sutures of catgut are then passed through the peritoneal coat, the first making a circle half an inch in diameter, the second surrounding the first, about half an inch from it. The ends of each suture are left long. A small incision is then made with a scalpel in the centre of the small circle, and through this is passed a No. 26 F. soft-rubber catheter. As this is being introduced, the first suture is tied so as to invert the peritoneum along with the catheter. The second suture is tied while the catheter is again pressed inward, still further inverting the wall of the stomach. The abdominal wound is then closed with layer or through-and-through silkworm-gut sutures ; the ones placed just above and below the emerging catheter also include the peritoneal coat of the stomach. The tube should be left in place five or six days, after which it may be removed and introduced only when a feeding is necessary. If the conical inversion of the stomach- wall is sufficient, no leakage will take place. Gastro-enterostomy. — This operation is indicated in malignant or benign pyloric stenosis, and in certain cases of gastric and duodenal ulcer. Several methods are in use. The one most frequently employed at present is called the posterior no-loop suture method. The abdomen is opened in the median line over the gastric area. The transverse colon is withdrawn and held upward. An opening is made in the trans- verse mesocolon through which the posterior wall of the stomach is drawn. The jejunum is next picked up at the duodenojejunal junction and drawn outward. Two clamps are then placed on the stomach and jejunum, as seen in Fig. 273. Mayo grasps the stomach wall in such a way that the line of anastomosis will be from above downward and to the. left, when the stomach is replaced. Moynihan prefers a perpendicular line, others one inclining slightly toward the right. When the clamps are in place, and the clamped folds of the stomach and intestine placed side by side, a continuous Gushing suture of silk or Pagenstecher linen thread is introduced for about three inches on one side of the proposed opening, uniting the peritoneal coats of the adjacent viscera. A longitudinal opening is next made into the stomach and intestine and the redundant mucous membrane removed. A second line of suture is next placed, uniting the adjacent cut edges of the stomach and gut and carrying it completely around the opening after which the outside peritoneal Cushing suture is completed. The structures are then replaced within the abdomen and the opening in the transverse mesocolon united about the line of anastomosis. It is sometimes desirable to make an anastomosis on the anterior 540 DISEASES OF THE ABDOMEN surface of the stomach. The techiiic differs only in the use of a longer loop of jejunum, passing upwards around the transverse colon, rather than through its mesentery. Some surgeons prefer to employ the Murphy button for the anas- tomosis. When this is employed, the gastric opening should he near the greater curvature in the most dependent part of the posterior wall. Murphy himself employs an oblong button, which insures a larger stoma. I i ' ; - 273. — Stomach and jejunum in the grasp <>f the large clamps, made ready for suturing. Small forceps still marking low point of stomach. (Mayo.) DISEASES OF THE INTESTINE. Intestinal Obstruction or Ileus. — Intestinal obstruction, or ileus, may occur as an acute or chronic condition. It is a term applied to a stoppage of the fecal current due either to paralysis of the intestinal muscle, or to mechanical occlusion, partial or complete, of some portion of its lumen. It is associated with abdominal pain, vomiting and distension. Etiology. — The chief cause of the paralytic type is peritonitis. Mechanical occlusion is caused most frequently by bands or adhesions following previous operations or attacks of peritonitis, of the latter. appendicitis and pelvic inflammations being the chief causes. It may also be due to lodgment of intestine in abnormal pockets of the omentum or mesentery, in hernial orifices, internal or external; to the lodgment of foreign bodies, or to twists or kinks due to the pressure of intra-abdominal tumors, cysts or abscesses. Next in frequency to bands or adhesions as an etiological factor is intussusception, or imagination of one portion of the bowel into another (Fig. 274). This occurs chiefly in young children. In these cases an important causative factor seems to be overactive peri- stalsis, due to digestive disturbances; or, sometimes, to traumata, such as falls or strains. Several varieties are recognized, first, the DISEASES OF THE INTESTINE 541 ileocecal variety in which the ileocecal valve forms the apex of an intussusception and drags with it the invaginated cecum and ileum; second, the ileocolic where the ileum is first invaginated through the valve. Other forms are the enteric, in which the lesion is confined to the small intestine; the colic, in which it is confined to the colon. The portion of the gut invaginated is called the intussusceptum. The constriction is apt to be greatest at the neck of the intussusception, increased by edema and venns stasis, and it is here that gangrene or perforation most commonly occurs. Sloughing off of the gangrenous intussusceptum, and spontaneous discharge through the bowel, with recovery, has been reported a number of times, but is rare. *V£[^SU5 Fig. 274. — Showing relations of component parts of an intussusception. Volvulus, or rotation of a loop of gut on its mesenteric axis, is respon- sible for another group of cases occurring most frequently in adults past middle life, and in more than half the cases in the sigmoid flexure. Cases of acute intestinal obstruction are sharply divided into two groups; those due to simple occlusion, and those due to occlusion associated with strangulation, or interference with the circulation. Symptoms. — The symptoms of acute intestinal obstruction are pain, obstipation, abdominal distension, and prostration. If the obstruction is incomplete, the pain is colicky, wave-like, generally referred to the region of the umbilicus. If complete, the pain is more constant, and if strangulation is present, it is greatly increased in severity. Vomiting is perhaps the most characteristic symptom. It consists, first, of stomach contents; then bile; and, finally, of intestinal matter. When the obstruction is complete, vomiting is persistent. Vomiting of intestinal contents is pathognomonic of obstruction. Intestinal distension develops early and increases steadily, owing to the formation of gas from decomposing intestinal matter con- fined above the obstructed area. This process also develops highly poisonous substances which by their absorption give rise to the excessive toxemia and shock w^nch always accompany this condi- tion. Prostration is marked and increases rapidly. Its degree de- pends upon the presence or absence of strangulation, and as to 542 DISEASES OF THE ABDOMEN whether the obstruction is complete or incomplete at the site of the stricture; obstructions high in the small intestine causing profound prostration in a much shorter time than those situated lower down. The pulse rises, becomes small and weak, the tem- perature is normal, or subnormal; cyanosis, cold perspiration, and symptoms of collapse develop as the condition progresses. If necrosis or gangrene of any part of the bowel occurs, perforation and peri- tonitis may develop. Many cases come to the surgeon so late and so desperately ill that a diagnosis of the cause of the obstruction is impossible prior to operation. Certain facts, however, may suggest the probable existence of one or the other of the usual varieties. Thus a history of previous peritonitis in an adult, or a recent abdominal section, would suggest strangulation by a band of adhesions; a gradu- ally developing sausage-shaped tumor in the region of the colon in a child with bloody stools, or the presence of a protruding mass in the rectum, would warrant the diagnosis of intussusception. Acute sudden pain and tenderness in the left inguinal region in an adult with the classic symptoms of obstruction would lead one to think of volvulus; while the presence of a localized, hard, movable tumor in the region of the cecum or sigmoid would point to a foreign body. The symptoms of intussusception differ from those of other forms of obstruction. The onset is usually sudden, with colicky pain, vomiting and often a movement of the bowels. Pain and vomiting continue, with passages of blood-tinged mucus and gas, but little or no fecal matter. Distension is moderate, and usually a sausage-shaped mass can be felt on the right side of the abdomen, or somewhere along the line of the colon. Occasionally the apex of the intussusceptum can be felt with the finger in the rectum. Prognosis. — The prognosis of acute intestinal obstruction depends largely upon the time which has elapsed before surgical relief is obtained. High obstructions, and those associated with strangulation, are the most rapid in course and the most fatal. Cases which have reached the stage of fecal vomiting and chronic prostration are attended with a high mortality. In intussusception the prognosis is good if the condition is recognized early, and operation performed before change in the gut necessitates resection, or before prostration is too profound. Treatment. — This invariably should be surgical, and should be instituted as soon as the diagnosis is made. In case of suspected early intussusception, reduction may be attempted by distension of the colon with gas or water, but prolonged attempts should be avoided, as they tend only to weaken the patient, and render him less liable to bear the strain of operation. With early operation reduction of the intussusception by direct manipulation often is possible, and recovery is the rule. If gangrene or necrosis is present, or if the edema or necrosis present at the neck prevents reduction and resection has to be performed, the prognosis is grave. Clubbe advises a forcible oil enema after the patient is under the anesthetic, believing that this aids the reduction and reduces the DISEASES OF THE INTESTINE 543 number of cases requiring resection. A longitudinal incision over the invaginated mass may be made in irreducible cases, resection of the mass and anastomosis by the Maunsel's method; or, the entire affected area of the gut may be excised. Kredel and Codman have recommended enterostomy in irreducible cases, combined with ligation of the mesenteric arteries over the intussusceptum, with a view to favoring rapid sloughing and discharge by the rectum. After the gangrenous mass is cast off the enterostomy wound should be closed. In operating for acute ileus, great care should be taken to prevent evisceration, because escape of distended bowel from the abdomen, with the attending trauma in handling and the great difficulty of returning and retaining them often leads to a fatal termination. If the distension is great and the cause of the obstruction cannot be located and relieved, the choice has to be made between a temporary enterostomy, leaving the relief of the mechanical obstruction to a later operation; or an enterotomy with an attempt to empty the distended coils and gain more room for operation. If in a strangulated loop of intestine there is doubt of its vitality it may be drawn out of the abdomen, suitably protected with gauze, leaving the question of replacement or enterectomy, to be determined at a later period. In cases of volvulus, the bowel should be untwisted and anchored in such a way as to prevent a recurrence of the condition. If the twisted loop is gangrenous, it must be resected. In obstruction due to foreign bodies in the intestines, large impacted gallstones, etc., it is well, if possible, to move the obstructing body backward into a healthy portion of the gut before making an incision for its removal. Chronic Intestinal Obstructio'n. — Chronic intestinal obstruction is due usually to a gradual narrowing of the lumen of the intestine, and consequently is always incomplete during the period of develop- ment. It may be due to stricture resulting from the healing of an ulcer, to the growth of an innocent or malignant tumor within the lumen of the bowel or infiltrating its wall; to outside pressure of tumors, bands or adhesions, foreign bodies or impaction of feces. Symptoms. — The symptoms are a gradually increasing constipation, attacks of wave-like colicky pain accompanied with more or less distension, relieved by purgation. As the condition progresses, attacks of complete obstipation, with pain, distension and vomiting occur. The pain often will commence at some definite area in the abdomen near the site of the obstruction, radiating from there to other portions; or it may be general, or variable in its location and occurrence. The attacks already described sooner or later terminate in complete obstruction, with its attendant symptoms, varying with the site of the obstruction, the majority of cases of chronic obstruction being located in the large intestine, or the lower ileum. When due to bands or adhesions, there is generally the history of attacks of peritonitis or of some abdominal operation. If due to strictures, there may be a 544 DISEASES OF THE ABDOMEN preceding' history of ulceration of the bowel. Obstructions by large gallstones are sometimes preceded by a history of cholelithiasis, but often this cannot be elicited. The character of the distension is sometimes an aid in locating the site of the obstruction, as a rule ovoid distension without involve- ment of the colon indicating obstruction in the ileum; distention in the flanks with an abdomen relatively flat in the centre, usually means obstruction in the descending colon. Visible peristalsis, and a feeling of stiffening of the bowel due to rhythmic muscular contraction of the coils proximal to the obstruction, are valuable signs when present. Loss of body flesh and strength and general failure of health accom- pany the progress of the disease, such symptoms being generally more marked in obstruction due to malignant disease. In all cases of chronic obstruction, digital examination of the rectum and sigmoidoscopy should be practiced. Treatment. — Except in eases of fecal impaction, which should be relieved by enema ta, catharsis, and the mechanical removal of the mass from the rectum, all cases of chronic intestinal obstruction should be treated surgically, and, if possible, before the symptoms become urgent. Early exploratory laparotomy should be performed, if there is reason to believe that mechanical obstruction of the bowel exists. Whatever the cause of the obstruction, the danger of the operation is greatly increased if performed in the presence of chronic distension. In cases requiring resection, as, for constricting growth of the colon, if such distension is present and cannot be relieved by medical means, it is better to do a preliminary colostomy, leaving a resection for a later operation. It is not alone the added mechanical difficulty and trauma, but the fact that the resistance of such patients is greatly lowered by the absorption of toxins from the obstructed bowel, which always increases the mortality of serious operations performed in the presence of distension. If the Cause of the obstruction cannot be definitely removed, short circuiting around the obstructed portion may be feasible. Or, if this is impossible, a permanent artificial anus above the obstruction should be made. This applies only to obstructions in the large bowel, as per- manent artificial anus in the small intestine is followed by emaciation and marked asthesia as well as by excoriation of the surrounding skin from the irritating character of the contents of the small intestine. Ulcers of the Bowel. — Ulcers of the bowel below the duodenum may be caused by typhoid fever, dysentery, tuberculosis, syphilis, actino- mycosis, intestinal obstruction, or by the presence of foreign bodies, enteroliths, or fecal concretions. These rarely come under the care of the surgeon unless perforation occurs. Typhoid Perforation. — Typhoid perforation of the intestine occurs in a considerable number of cases, about one-third of the deaths being due to this complication. According to Haggard's statistics, it occurs most frequently in the third week of the disease, although cases have been reported as early as the first and as late as the fourteenth week. DISEASES OF Till': INTESTINE 545 In over !)."> per cent, of the cases the lesion occurs in the ileum, generally within eighteen inches of the cecum. The lesion is usually single, and generally is found to be a small pinpoint perforation on the surface opposite the mesenteric attachment. Occasionally several perforations are present. The perforation usually is surrounded by an infiltrated area which is exceedingly friable, and this condition frequently renders closure by sutures difficult. Symptoms. — The symptoms of perforation in typhoid fever are often obscure, and are masked by the symptoms peculiar to the dis- ease. The evidences at first are those of peritoneal irritation, pain, tenderness, and muscular rigidity. The development of even a slight degree of localized tenderness and muscular rigidity during the course of a typhoid, especially when following a sharp increase in abdominal pain, should be regarded as definite warning that a perforation has occurred, or is impending. At a later period the symptoms are those of a spreading peritonitis, pain, vomiting, increased tenderness and rigidity, meteorism, and a rapidly progressive prostration. Leukocy- tosis may be an early symptom, and is generally present after peritonitis develops. The presence of free fluid and gas in the peritoneal cavity is conclusive evidence of perforation, but these signs are rarely observed in the early stage. A sudden fall in the temperature and rise in the pulse rate is significant, and when combined with symptoms of peri- toneal irritation is strong confirmatory evidence of a perforative lesion. Prognosis. — The prognosis in untreated cases is exceedingly bad, the death-rate, according to Murchison, being from 90 to 95 per cent. By timely operation from 25 to 30 per cent, of the cases can be saved. Treatment. — While the condition of a typhoid patient with perfora- tion of the intestine is always such as to render any surgical operation extremely hazardous, immediate laparotomy, closure of the intestinal wound, and cleansing the peritoneal cavity, are positively indicated in all cases seen sufficiently early, and in which, the physical condition is not so grave as to contra-indicate the administration of an anesthetic. A thorough operation performed with the maximum of speed and the minimum of anesthesia and exposure, combined with the judicious use of stimulants, especially the intravenous infusion of saline solution, will occasionally save a patient even under conditions which seem most unfavorable. In rare instances it may be advisable to employ local or spinal anesthesia. Dysenteric Ulcerations. — Dysenteric ulcerations of the large intestine rarely perforate, but they frequently prove fatal by the exhausting diarrhea and hemorrhage which they provoke, as well as by the hepatic suppuration which sometimes follow s. Treatment. — After all reasonable medical measures have been tried, a right-sided colostomy, with frequent irrigation and rest of the colon, may bring about cure. Complete extirpation of the colon has been performed with success in a few of these cases. 35 546 DISEASES OF THE ABDOMEN Tuberculosis of the Gastro-intestinal Tract. — Gastric Tuberculosis. — Tuberculosis of the stomach is an exceedingly rare disease. It is generally associated with tuberculosis of the lungs and other organs. Symptoms. — The symptoms are those of chronic ulcer, and the diagnosis is established by the demonstration of tubercle bacilli in the stomach contents. Tuberculous ulceration of the bowel is of more frequent occurrence than that of the stomach, but it is generally secondary to tuberculosis elsewhere, and belongs rather to the domain of internal medicine. Ileocecal Tuberculosis. — Hartman and Pilliet, in 1891, called attention to a form of hyperplastic tuberculosis of the intestine resulting often in tumor formation and stenosis. While this condition may occur in any part of the small or large intestine, in over 80 per cent, of the cases it involves the ileocecal region. In these cases there is a diffuse infiltration of the cecal wall, which generally extends to the ileum and appendix. The mass grows slowly, often without symptoms at first, and not infrequently is mistaken for a neoplasm. Symptoms. — The symptoms of ileocecal tuberculosis are, in the beginning, those of an indefinite digestive disorder; moderate pain and tenderness, diarrhea, and loss of appetite and weight. Later, as stenosis develops, the pain is of a colicky character and is often referred to the umbilical region. Still later, pain and tenderness in the right iliac fossa suggest the diagnosis of chronic appendicitis. ^Yhen a palpable tumor is present, carcinoma or sarcoma often is suspected. The disease occurs most frequently in individuals between twenty and forty years of age. In doubtful cases the tuberculin reaction is of value. Treatment. — As the disease produces stenosis in the majority of instances, complete extirpation of the diseased area is to be advised. This, in most cases, is best accomplished by a two-stage operation: the first consisting of an ileocolostomy; the second, an extirpation of the diseased area. The mortality of the operation carried out in this manner, in suitable cases, is not over 12 per cent. Actinomycosis of the Intestine. — As stated elsewhere, in about 50 per cent, of the cases of intestinal actinomycosis, the lesion is located in the ileocecal region. The disease resembles, in its early stages, the hyperplastic type of tuberculosis. There is a massive infiltration of the intestinal wall, which later extends to the abdominal parietes, producing a brawny induration, with fistula?. The discharge is generally thin and watery, may be purulent from mixed infection, and contains the characteristic lemon-yellow granules. Treatment. — The treatment of this condition should be by hygiene, opening and draining suppurating foci, and the exhibition of potassium iodide and the salts of copper. If the diagnosis of the primary focus could be made sufficiently early, radical removal would, of course, constitute the ideal treatment. Diseases Caused by Congenital or Acquired Diverticula of the Intestine. — Intestinal diverticula, as is well known, are divided into t wo jf general classes — the congenital and the acquired. The most DISEASES OF THE INTESTINE 547 frequently observed type of the congenital variety is the one known as Meckel's diverticulum. As recently described by Leon Cahier, in his admirable essay upon the subject, a Meckel's diverticulum possesses the following characteristics: "It is single; it has a rectangu- lar implantation into the free border of the terminal portion of the ileum, generally in the neighborhood of the ileocecal valve; it is made Fig. 275. — Acquired diverticula of sigmoid. up of all of the coats of the intestine; it is generally more than 2 cm. in length ; and it has a terminal filament which may be free or attached to the abdominal wall, the mesentery, or another part of the intestine." The acquired diverticula, on the other hand, are, as a rule, multiple, small, thin walled, and round or ovoid in shape. They may be found in any part of the intestinal canal, but are more frequent in 548 DISEASES OF THE ABDOMEN the left colon and the rectum, and are, in reality, hernial protrusions of the mucous membrane through the separated fibres of the muscular coat (Fig. 275). Acute Diverticulitis. — An acute inflammation of Meckel's diverticu- lum may simulate an acute appendicitis so accurately that a differential diagnosis is not possible. The writer recently operated upon such a case, and on opening the abdomen found the diverticulum, acutely inflamed, lying in the right iliac fossa. In appearance and size it so closely resembled an inflamed appendix that the true nature of the condi- tion was not recognized until its relation to the ileum was demonstrated. Fig. 276. — Acute diverticulitis of sigmoid. Treatment. — The treatment in these cases should be removal of the diverticulum when this is possible and closure of the iliac wound by Lembert sutures. When this is not practicable, either from the size of the junction or from the presence of gangrene, intestinal resection is to be recommended. Acute Diverticulitis of the Sigmoid. — Acute diverticulitis of the sigmoid or colon has only recently been recognized as a distinct surgical disease. In 1907 the author reported to the American Surgical Asm>- ciation a series of cases of left-sided intra-abdominal infection, in two of which the cause of the symptoms was proved to be the rupture of an acquired diverticulum of the sigmoid. DISEASES OF THE INTESTINE 549 Symptoms. — The symptoms of acute diverticulitis of the sigmoid are pain, tenderness, and muscular rigidity in the left iliac region. Fever quickly follows these initial symptoms, and leukocytosis is generally present. If rupture occurs, symptoms of spreading peri- tonitis may quickly develop, or if the process is limited by adhesions the signs of an intra- or extra-abdominal abscess will appear. The clinical history of these cases so closely resembles that of acute appendicitis that one instinctively thinks of a transposition of the viscera. Fig. 27(5 represents the condition found at operation in a case reported by the writer to the surgical section of the American Medical Association in June, 1908. Treatment. — Regarding the treatment of this condition it may be stated that sufficient data are not available to enable one to deter- mine what percentage of inflamed diverticula actually perforate, and it is, therefore, not. possible to state dogmatically whether a given case of acute diverticulitis with comparatively mild symptoms should be subjected to immediate operation or should be treated more conser- servatively. In the writer's opinion, however, the clinical course of the disease is so similar to the various forms of acute appendicitis that the treatment should be the same. Certainly in all acute cases with severe and progressive symptoms safety lies in early operation. If the diverticulum is small or attached to the bowel by a narrow pedicle, removal with closure of the intestinal wound by a purse-string or several Lembert sutures would be indicated, provided the surrounding intestinal wall was not too much infiltrated. In the event of the diverticulum being large, attached by a broad base, or covered by a plexus of enlarged vessels, the safest method would be to deliver the affected loop of intestine through the abdominal wound and treat it temporarily as an extraperitoneal lesion. If the situation of the lesion is such that extraperitoneal treatment cannot be carried out, packing with gauze from the abdominal wound to the lesion is to be advised, leaving this packing in place from forty-eight to seventy-two hours, or until firm adhesions have formed around the gauze column; then removal of the gauze and free opening of the abscess, allowing it to drain through the channel thus formed. If rupture has already occurred, the intestinal wound should be united by suture, if this is possible; if not, adequate drainage should be provided. In the treatment of spreading peritonitis or intra-abdominal abscess from this cause the same principles should be followed as in other abdominal conditions. Chronic Diverticulitis of the Sigmoid. — William J. Mayo recently called attention to a chronic form of acquired diverticulitis of the sigmoid, which, in its clinical history and gross appearances at operation, strongly resembles carcinoma. The disease usually occurs at the cancer age, and gives rise to a slowly progressive stenosis with tumor formation. 550 DISEASES OF THE ABDOMEN Excision of the diseased area is indicated in those cases in which mechanical obstruction exists or is imminent. Obstruction or Strangulation of the Bowel. — Obstruction or strangula- tion of the bowel not infrequently occurs as a result of a loop of intestine being incarcerated under a Meckel's diverticulum, the distal extremity of which is attached to the mesentery or abdominal wall. The symp- toms and treatment of this condition are considered in the section on Intestinal Obstruction. TUMORS OF THE INTESTINE. Tumors of the intestine, as in other regions, are divided into two general classes, the innocent and the malignant. Of the innocent tumors, fibromata, myomata, adenomata, lipomata, and cysts are described by Maylard 1 as occurring in the small intestine; and papillo- Fig. 277. — -A carcinoma of the sigmoid, causing total obstruction. (Drawn from a specimen removed by Dr. W. T. Bull.) mata, adenomata, fibromata, and lipomata in the large bowel. Car- cinomata and sarcomata occur in all parts of the canal, the former being more common in the large, the latter in the small intestine. As a rule, the non-malignant tumors grow slowly and give rise to no disturbance until they attain a sufficient size to produce obstruction. The fibromata, myomata, and adenomata generally form polypoid masses; the lipomata arise from the submucous tissue and may be multiple. All of these conditions are rare. An intestinal polypus not infrequently induces intussusception. In such cases the tumor is often found at the apex of the projecting mass. Cysts of the intestine or mesentery are rare, but form an interesting group on account of their etiology. Dowd believes most of them to be of embryonic origin. They vary in size greatly, may contain a clear 1 The Surgery of the Alimentary Canal. TUMORS OF THE INTESTINE 551 serous fluid or chyle. They rarely give rise to symptoms calling for surgical intervention. Carcinoma of the large intestine is generally of the columnar cell variety. The tumor, as a rule, grows around the gut and forms a constriction similar to that which would be produced by tying a piece of twine about it (Fig. 277). In other cases the growth infiltrates the walls, almost invariably grows concentrically and produces stenosis. If extremely cellular, it is often described as medullary or encephaloid cancer; if fibrous, as scirrhous. It may undergo colloid degeneration and spread rapidly to other abdominal organs. Sarcoma occurs as a polypoid growth, projecting within the canal or as a rapidly infiltrating tumor thickening the walls of the canal, growing eccentrically and producing dilatation. The first form is usually of the spindle-cell variety; the second, the round-cell or lympho- sarcoma. Both varieties arise from the submucous layer. Lympho- sarcoma of the small intestine may occur in any part. It grows with great rapidity and extends to the surrounding peritoneum. It may occur at any age, but is rare after forty. Carcinoma, on the other hand, is more common after forty, although Lib man states that not infrequently it has been reported in individuals between fifteen and twenty-five, and has been observed as a congenital affection. Symptoms. — Growths of the duodenum are exceedingly rare. When sufficiently developed, they produce symptoms of obstruction. If situated high up, the obstruction resembles that of pyloric stenosis. If lower down, there may be, in addition, obstruction of the common bile duct and ca.nal of Wirsung. In these cases the patients rapidly emaciate, and jaundice and vomiting are prominent symptoms. Innocent tumors in the small intestine situated below the duodenum rarely give rise to symptoms unless they act as the exciting cause of an intussusception or other forms of obstruction. Papillomata of the large intestine may give rise to hemorrhages. Maylard cites two cases in which large numbers of these tumor were found in the colon, in one of which carcinomatous degeneration had occurred at one point and transitional forms at several others. The symptoms were localized pain and the passage of mucus and blood. In carcinoma of the small intestine the symptoms are those of a progressive chronic obstruction coupled with rapid loss of weight and strength and anemia. Vomiting is more frequent and occurs earlier than in carcinoma of the large intestine. The tumor can rarely be detected until the symptoms of obstruction are manifest. In Carcinoma of the Large Intestine the symptoms depend upon the type of growth : if of the constricting form — the most common type — there is gradually increasing constipation merging into attacks of obstipation; pain, which may be a dull aching at or near the site of the growth, becomes, as obstruction increases, wave-like, colicky, intermittent in character, and due to the obstruction. Abdominal distension follows later and often is accompanied by 552 DISEASES OF THE ABDOMEN visible peristalsis, or the feeling of "stiffening" of the bowel above the site of the obstruction. Hemorrhage may occur, but is often absent or slight in amount in the constricting type. Constitutional symptoms are loss of weight, loss of strength, and general cachexia. If the growth is of the infiltrating, non-constricting type, hemorrhage is apt to be an early symptom, with pain in the region of the growth but not the colicky pain of obstruction. Diarrhea, with blood and mucus in the stools may be the first indication of the trouble if located in the right colon and later, alarming hemorrhage may come from the ulcerated surfaces. Tumor may be felt in either type, or may be absent, especially in the constricting form, and in those situated low in the splenic flexure or in other inaccessible sites. In sarcoma of the small intestine the symptoms may at first be extremely obscure. The growth of the tumor is usually rapid, and in the majority of cases no obstruction exists. In many cases the symptoms are those of an acute intra-abdominal inflammation: localized pain, tenderness, muscular spasm, and the presence of a large indurated mass resembling an inflammatory exudate. Fe\er may be present, which still further obscures the diagnosis. Lil n an reports that of 5 cases of sarcoma of the small intestine admitted to the Mount Sinai Hospital, in two years, 3 were sent in with a diagnosis of acute appendicitis. Sarcoma of the large intestine is exceedingly rare. It occurs generally in the cecum. Ulceration of malignant growths of the intestine is of frequent occurrence in the later stages; and perforation may occur, gi\ ing rise to a localized or spreading peritonitis, or to an intra- or extra- peritoneal abscess. Tuberculosis or syphilis of the intestine may occasionally give rise to tumors which closely resemble carcinomata or sarcomata. The former condition is described as hyperplastic intestinal tuberculosis; in the latter condition the lesions are generally gummatous in character, and may extend into the mesentery. Accurate diagnosis from gross appearance is often impossible. Treatment. — Innocent tumors of the intestine rarely come under the care of the surgeon unless they produce obstruction or hemorrhage. They are, however, occasionally encountered in operations for intestinal obstruction, and should be removed by enterotomy or resection of a portion of the bowel. Treatment of Malignant Tumors of the Intestine. — If the growths are adherent to surrounding structure, have formed secondary deposits in the liver or retroperitoneal lymph nodes, or have infiltrated surround- ing tissues, they are inoperable and can be treated only by palliation. This may consist in laxatives, enemata or irrigations to keep the bowels open; tonics, nourishing food and sedatives, as needed for the pain. Or, if obstruction is present, colostomy may be performed above the OPERATIONS ON THE INTESTINE 553 growth, or short circuiting by anastomosis between proximal and distal loops. These means may prolong life and lessen the suffering for some months, as many of the growths arc relatively slow in progress. Radical Treatment consists in the removal of the growth with a sufficient length of intestine to get well beyond the disease. In tumors situated in the large intestine above the rectum excellent results may be obtained by radical excision, as anatomically it is not difficult to remove sufficient adjacent tissue and neighboring lymph nodes. The growths are often relatively slow in type, and late in forming lymph node metastasis. Enlarged glands in the neighborhood of the growth are not alone contra-indieation to radical operation for they have been proved in many instances to be inflammatory and not neoplastic. The result- of excision of malignant growths of the rectum are much less satisfactory. Malignant growths of the small intestine are rare, and should be treated on the same general principles. In Sarcoma of the Intestine, the outlook is much less favorable unless it be of the polypoid type. Libman was unable to find a case in liter- ature that had passed the third year limit. Operation for radical removal of intestinal growths should never be undertaken in the presence of ileus or obstruction, as it adds greatly to the mortality. If it is impossible to relieve distension by enemata or medical means prior to operation, a preliminary colostomy or enterostomy should be performed, followed later by radical operation. OPERATIONS ON THE INTESTINE. All operations on the upper bowel should be preceded by careful frequent disinfection of the oral cavity, stomach lavage, and the ingestion of only sterilized food and water for thirty-six hours before the proposed operation. Enterotomy. — Enterotomy is an incision into the large or small intestine for purposes of diagnosis or for the removal of tumors or foreign bodies. The abdomen is opened and the bowel drawn into the wound, the peritoneal cavity being protected by gauze pads, the incision into the bowel should be made in a longitudinal direction, and closed with the Lembert or Halsted suture. Enterectomy. — Enterectomy, or removal of a section of the intestine is indicated for the extirpation of a new growth or stricture, the cure of an obstinate fecal fistula, or in the treatment of extensive wounds or gangrene of the gut. If the portion to be removed is movable and has a mesentery, it is drawn outward through an abdominal incision, the peritoneum carefully protected with gauze pads, and the lumen of the bowel above and below the diseased or injured area closed by clamps or gauze ligature. A V-shaped incision is then made, including the intestine and a portion of the mesentery, the vessels ligated, and the mucous edges disinfected with hydrogen 554 DISEASES OF THE ABDOMEN peroxide or bichloride solution. The two ends may then be united by circular enterorrhaphy or by the Murphy button. If the portion to be removed is fixed and has no mesentery, as the cecum, the ascending or descending portions of the colon, it is often wiser to make the operation in two stages. At the first operation the intestine above the diseased portion is united by lateral anastomosis to the part below the area to be removed; as, for instance, uniting the ileum with the transverse colon in disease of the cecum, or the transverse with the descending or sigmoid colon in a lesion of the splenic flexure. At the second operation the diseased area is removed, and the two divided ends closed by a purse-string suture and reinforced by additional Lembert sutures or an omental graft. Fig. 278. — Connell's suture: Method of inserting needle for tying the last knot. (Kelly- Noble.) It is obvious that in cases of acute trauma or gangrene both procedures must be carried out at the same time. Circular Enterorrhaphy. — This may be accomplished by means of the Cushing or Connell suture. If the former method is employed, the two ends of the divided intestine are approximated by fixation sutures or small forceps, and a continuous Cushing suture carried around the circumference. Each stitch includes the serosa muscularis and submucosa, and is introduced about one-quarter of an inch from the free border. Great care should be taken to insure complete closure of that portion of the bowel between the two layers of the mesen- tery; and, as there is no peritoneum to unite at this point, a small portion of the mesentery may be inverted to insure early adhesion. OPERATIONS ON THE INTESTINE 555 If the Coimell suture is employed, the two open ends of the gut to be united are placed side by side, with the mesenteric border of each iu contact. Lateral traction sutures are next placed to insure a uniform approximation. A continuous suture is next introduced, including all the tunics of the bowel, and by changing the position of the traction sutures about three-quarters of the circumference of the gut can be rapidly united from within. In introducing the last few stitches the edges must be separated, but the same form of suture continued until the entire circumference is united. The two extrem- ities of the suture are then drawn into the lumen of the bowel and again outward at another point in the circumference by means of a blunt-pointed Reverdin or ordinary threaded needle introduced backward (Fig. 278). By gentle traction on the suture the two mucous surfaces are approximated and the knot tied. As soon as the remaining ends are cut away the knot sinks inward and leaves a smooth line of peritoneal approximation throughout the entire circumference. Fig. 279. — Murphy button. Anastomosis by the Murphy Button. — This is the quickest and often the safest method of intestinal anastomosis. The Murphy button (Fig. 279) consists of two perforated metal disks, each having a hollow metal stem of such a size that one telescopes into the other, and is securely held in place by a spring catch acting on a thread on the interior of the female stem. By this contrivance the divided ends of the intestine can be securely held in place by approximating their inverted peritoneal coats. Union takes place externally, and the inverted edges eventually slough, allowing the closed button to become free and to pass outward along the intestine. The method of anasto- mosis by the button is as follows: A continuous suture of silk or catgut is carried around the free edge of the gut, making a double turn at the attachment, of the mesentery. One-half of the button is introduced and the suture tied (Fig. 280); the other half is placed in the other end of the divided intestine and secured in the same manner; the two are then united and the button firmly joined by pressure (Figs. 281 and 282). After careful disinfection and suture 550 DISEASES OF THE ABDOMEN of the divided mesentery the united intestine is dropped into the peritoneal cavity and the wound closed without drainage. Fig. 280. — The two portions of the Murphy button held in position by purse-string sutures. (Richardson.) Fig. 281. — End-to-end approximation; button in position. (Richardson.) Fig. 282. — End-to-end union of intestine with a Murphy button. (Richardson.) Maunsel's Method of Enterorrhaphy. — In this operation the divided ends of the intestine are united by two silk sutures, one at the mesen- teric border and one at the free opposite border. An incision is then OPERATIONS ON THE INTESTINE 557 made longitudinally into the bowel an inch or more from the divided ends on the distal side of the anastomosis, and through this incision the two silk sutures are carried (Fiji - . 283). Drawing these sutures outward through the longitudinal wound invaginates the two approxi- fFTfOTvipiR Fig. 2S3. — Maunsel's method: first two sutures brought out through the incision in the lower segment. mated portions, which are eventually drawn outward through the distal opening (Fig. 284). The approximated edges are then united by a continuous silk suture penetrating all three coats. When this is completed, the invaginated gut is reduced and the longitudinal wound united by Lembert sutures. After union of the mesentery and disinfection of the parts the intestine is returned to the abdominal cavity and the parietal wound closed. J l {/ ' ' {V ) ' i Fig. 2S4. — Maunsel's method; protruding ends ready for suture. Lateral Anastomosis. — Lateral anastomosis is often necessary to sidetrack a stricture of the intestine or to unite the bowel after enter- ectomy when one portion is immovable or only partly surrounded by peritoneum, as in the case of the ascending or descending colon. 558 DISEASES OF THE ABDOMEN It generally can be accomplished by the use of the Murphy button introduced as in gastroenterostomy. Abbe's method consists in closing both ends of the divided intestine by purse-string sutures, placing the two portions of the bowel side by side and uniting them for a distance of two or three inches by a con- tinuous peritoneal suture of silk or linen, leaving the suture long at each extremity of the line. Next incise both portions of the intestine one- quarter of an inch from the suture line, introduce a second line of catgut sutures uniting the adjacent cut edges of the gut, and carry it entirely around the opening; then introduce an outer row of peritoneal sutures on the side opposite to the first row, tying each extremity to the long ends left of the first peritoneal suture. Colostomy. — This operation is indicated in carcinoma of the sigmoid or rectum, and in other cases in which temporary or permanent absence of fecal discharges through the rectum is desirable. Maydl's method consists in making an incision in the left inguinal region parallel with the fibres of the external oblique aponeurosis, and carry - Fig. 285. — Inguinal colostomy. (Tillmanns.) ing the incision through all layers until the peritoneal cavity is opened. The upper part of the sigmoid flexure is found and drawn outward through the wound. A glass rod is passed through its mesentery and allowed to project on either side on the abdominal wall, to prevent return of the loop or gut. The peritoneum may be stitched to the protruding intestine and the wound partly closed (Fig. 285). When possible, the opening into the bowel should be delayed for twenty -four or forty-eight hours, until the peritoneal cavity is thoroughly sealed by adhesions. Colostomy occasionally may be necessary at a higher point in the colon. In the transverse portion there is little difficulty in withdrawing a knuckle of the bowel; but in the cecum, ascending or descending colon, this may be impossible if there is no mesentery. In these cases the presenting portion of the colon may be united to the parietal peritoneum, and the edges of the opening kept apart by gauze packing until adhesions have formed, after which the bowel may be incised. Weir's method of establishing a permanent artificial anus is to divide completely the sigmoid, close the distal portion and drop APPENDICITIS 559 it back into the pelvic cavity, then carry the proximal portion beneath the skin to an opening just over the crest of the ilium, to which its edges are united. This insures freedom from fecal invasion of the lower segment and an artificial anus which can in a measure be controlled. APPENDICITIS. The vermiform appendix is an anatomic relic due to gradual reduc- tion in size of the cecum. In man and the anthropoid apes it is found as a diminutive blind intestinal tube opening into the caput coli. It possesses the same anatomic structure as the intestine. Its mucous membrane is richly supplied with lymphoid tissue. So abundant is this tissue that sometimes the appendix is spoken of as the abdominal tonsih Its cecal orifice is guarded by a fold of mucous membrane, the valve of Gerlach. Under ordinary conditions the abundant secretion of the mucous membrane of the appendix finds its way easily into the intestine, and the valve of Gerlach serves to prevent the entrance of any considerable amount of intestinal matter. If the mucous membrane of the cecum becomes swollen as a result of some digestive disturbance or inflammatory process, the orifice may become temporarily occluded, causing retention of the secretions of the appendix. The muscular efforts of the appendix to rid itself of this excess of mucus may cause pain, and constitutes the condition known as appendicular colic. Other conditions may give rise to this same condition, as the presence within the lumen of the appendix of a small amount of fecal matter, the fluid portion of which has been absorbed, leaving a small oval mass which resembles in appearance a grape- or date-seed (a circumstance which accounts for the popular impression that the presence of such seeds is the cause of appendicitis 1 ). Expulsive muscular efforts on the part of the appendix to rid itself of this foreign body give rise also to appendicular colic. If for any reason this occlusion of the lumen of the appendix is not relieved, the organ becomes distended with mucus; pressure on the mucous membrane causes anemia and diminished resistance; the pathologic- micro-organisms always present (Bacillus coli and others) attack the anemic membrane and give rise to an inflammatory process which constitutes the acute catarrhal form of appendicitis. If the obstruction is speedily relieved, this may disappear without damage to the mem- brane. Generally, however, there has been some necrosis and loss of tissue, which by later cicatrization and contraction gives rise to stricture of the appendix, a condition which favors subsequent recur- rence of the trouble, and constitutes one of the forms of relapsing or recurrent appendicitis. If in an acute catarrhal appendicitis the distension is not promptly relieved, extensive infiltration of the mucous 1 Some years ago McBurney stated that he had seen only one grape-seed in the appendix, and that was discovered by accident during a laparotomy for another condition. The appendix in this instance was healthy. 560 DISEASES OF THE ABDOMEN membrane and of the submucous and muscular coats may occur from extension of the inflammatory process, constituting an acute interstitial appendicitis, in which the organ appears erect, hot, swollen, and intensely red. If the process extends, and especially if there is added thrombosis of the appendicular vessels or the pressure of a concretion cutting off or seriously compromising the blood supply, necrosis occurs, which may be limited in extent, giving rise to a perforation, acute perforative appendicitis, or a large part or the whole of the organ may slough, gangrenous appendicitis. In the simple catarrhal variety there is, as a rule, no involvement of the neighboring peritoneum; if, however, the process extends to the other coats of the appendix, and especially if the infecting agent is a virulent one, peritonitis may develop, even without perforation, from a transudation of septic material through the infiltrated walls of the organ. When perforation occurs, peritonitis always results unless the appendix is located behind the peritoneal membrane, as it occasionally is in the retrocolic variety. As in other peritoneal infections, the resulting peritonitis may be localized or diffuse. If localized, it may be plastic and result in a matting together of the neighboring viscera. This form is fairly common, and occurs often in cases before perforation has occurred. In the majority of cases, however, in which perforation occurs, an intraperitoneal abscess forms, the walls of which are formed by a mass of the intestine and omentum matted together with plastic exudate, separating the septic focus completely from the general peritoneal cavity. This constitutes an appendicular abscess. If the inflammatory process in the peritoneum which results from a rupture of an inflamed appendix is not quickly walled off by adhesions, or if the amount of septic fluid which escapes is large and covers an extensive area, or if the virulence of the infecting micro-organisms is great, a diffuse spreading or general peritonitis results. In abnormally placed appendices, outside the general peritoneal sac, abscesses may be produced which never communicate with that cavity. Thus in retrocecal or retrocolic appendices the abscess lies behind the peri- toneum in the flank, often as high as the kidney. Appendicular abscesses have also been reported on the left side of the abdomen or pelvis, and in the sac of a femoral hernia. Appendicular abscesses may develop slowly or rapidly, depending largely on the virulence of the infection and the resistance of the individual. They may rupture into one of the hollow viscera, exter- nally, or into the free peritoneal cavity, and thus occasion an acute spreading peritonitis. Symptoms. — The symptoms of acute appendicitis in the order of onset, are: pain, often at first in the epigastrium, shifting in a few hours to the right iliac region; nausea or vomiting, most commonly occurring from two to four hours after the onset of the pain; abdominal tender- ness, maximal in the right lower quadrant of the abdomen at McBur- ney's point; elevation of temperature, generally beginning within a APPENDICITIS 561 few hours after the onset of the pain; leukocytosis, which is very apt to accompany the rise in temperature. The order of onset of symptoms in acute appendicitis is of the greatest importance. J. B. Murphy lays much stress on this point and states that if nausea, vomiting, or fever precedes the pain, the case is not one of appendicitis. Pain is constant and uniform and practically never absent as an initial symptom; is apt to reach its height in from four to six hours, but may persist with great violence for a considerably longer time. Sudden cessation of the severe pain of appendicitis in the first thirty-six hours usually means either dis- charge of contents into the cecum, perforation, or complete gangrene. It is often an ominous sign, and must not be mistaken for an improve- ment in the condition. When followed in a short time by an increase of steady pain over a larger area, with increase in the area of tenderness and rigidity, it means developing peritonitis. Primary nausea and vomiting is reflex, usually occurs a few times only and ceases; if it continues or becomes persistent, it is indicative of peritonitis. Ab- dominal tenderness is often at first diffuse and indefinite, but soon localizes over the appendix. ^Yhen associated with rigidity, it means irritation of the parietal peritoneum and is a most valuable diagnostic sign. Tenderness may be slight and rigidity absent in appendicitis situated deep in the pelvis, or behind the colon, even when the process is acute. Development of a tumor or mass is due to inflammatory exudate surrounding the inflamed appendix, to thickened omentum, or to an abscess surrounded by exudate. The site of maximal tender- ness is often of aid in determining the position of the appendix. In- crease in the leukocyte count and percentage of polymorphonuclears varies with the amount of inflammation present. A low count with high polynuclear percentage may be present in acute gangrene and suggests a low degree of resistance. Some degree of elevation of temperature is seldom absent in the acute infective cases in the early stage. Cases of acute gangrene occasionally are seen, however, with so slight an elevation of temperature that the reaction seems out of proportion to the severity of the lesion. There is no typical temperature curve, and slight reaction counts little in estimating the severity of the case, although it often reaches 102° or 103° in the first twenty-four hours. The pulse rate usually conforms to the tem- perature, except in the more acute forms of gangrene and peritoneal sepsis, when it may be disproportionately rapid and weak. The symptoms as described apply to the typical case of acute appendicitis, and vary with the severity of the type. In appendicular colic, pain and perhaps slight tenderness are the only symptoms. In catarrhal appendicitis, vomiting and slight elevation of tem- perature are present in addition; rigidity is generally absent. As the more severe types are reached, the exudative, perforative or gangrenous, both local and constitutional symptoms are of the type described, varying with the severity of the case. 36 562 DISEASES OF THE ABDOMEN Course. — In appendicular colic, the pain and tenderness usually subside within twenty-four or thirty-six hours. In catarrhal appendi- citis, improvement in the symptoms usually begins about the end of forty-eight hours and all tenderness will have disappeared within three or four days. The line of demarcation between catarrhal appendicitis and the milder exudative types cannot he definitely drawn, one condition merging into the other; in the latter the symptoms being a little more severe and protracted, the tenderness of longer duration, and often accompanied by muscular rigidity. When there is an accumulation of pus or mucopurulent fluid in an occluded appendix without perforation, empyema of tin- appendix, the symptoms are still more severe, the leukocyte count especially being higher. Local perforation may cause a sudden cessation of pain, soon to be followed by an increase of pain, tenderness and rigidity and all the symptoms of a peritonitis which may remain localized or become diffuse. If localized, the case becomes one of an appendix abscess type already described. Chills and sweating may occur in the septic types of appendicitis, especially at the onset of gangrene. The symptoms of peritonitis due to appendicitis have already been described under the heading of "acute appendicitis." Absence of pain in appendicitis is very exceptional. Occasionally cases are encountered in which the disease goes on to the formation of an abscess or a spreading peritonitis without acute pain. Absence of marked fever is more frequent. The writer has on several occasions found a gangrenous appendix and a diffuse spreading peritonitis in patients in whom the pulse and temperature were both below 100. Diagnosis. — The diagnosis of appendicitis in its early stages is usually easy. In the presence of symptoms of beginning inflammation in the right iliac fossa in women, one must exclude salpingitis, in which the point of maximum tenderness is below McBurney's point, and is gen- erally more easily reached by vaginal examination. In this affection there is usually a history of previous infection either of a puerperal nature, the result of abortion or an invasion by the gonococcus. The uterus is more or less fixed and the roof of the pelvis is rigid. Typhoid perforation can be excluded by the history. An ulcerating carcinoma of the intestine, by the absence of symptoms of obstruction, and the loss of weight and strength which usually accompanies this disease before ulceration and perforation take place. Renal colic may stimu- late very closely appendicular colic, and a diagnosis between the two is not always possible. Tenderness over the kidney, pain radiating to the groin and testicle, absence of fever and muscular rigidity, and presence of blood in the urine, would point to a renal origin of the pain. Pain in the right inguinal region and tenderness over Mc- Burney's point are frequently present in women just before or during menstruation, but without fever or muscular rigidity. In hysteric subjects the pain may be severe, and require codiene or morphine for APPENDICITIS 563 its relief. Appendicular abscess may be simulated by a strangulated ovarian cyst, by a rapidly growing intestinal sarcoma, by a retro- peritoneal abscess of renal origin or from lymphatic infection From the lower extremity, genitals or pelvic organs, by tuberculosis or actinomycosis of the appendix or cecum, and by an acute inflammation of a congenital or acquired intestinal diverticulum. These can only be excluded by a carefully taken history, and in the case of tuber- culosis by the blood count. Psoas or iliac abscess may rarely simulate this condition. These generally can be excluded by the history of disease of the spine or pelvic bones, and by the chronicity of the affection. In palpating the contents of the iliac fossa Meltzer has recently called attention to the advantages to be gained by a contraction of the iliopsoas musde. By instructing the patient to raise the entire limb from the bed the muscle is brought nearer to the anterior ab- dominal wall, and any structure lying upon it can be more easily palpated. In the presence of symptoms of general peritonitis without localized signs, one must consider, in addition to the appendicular and tubal origins of such inflammations, a perforated gall-bladder, perforation of an ulcer of the stomach or duodenum, acute pancreatitis, divertic- ulitis, and intestinal obstruction. In the first four conditions the pain, tenderness, and rigidity begin in the upper part of the abdomen, whereas in appendicitis they begin below. In gall-bladder disease and in perforations of the stomach or duodenum there is usually a history of previous disease or disturbed function in these organs. In intestinal obstruction obstipation exists before symptoms of peritonitis, which generally results from a perforation of the bowel above the seat of ob- struction. In many of these late cases an accurate diagnosis is im- possible except by exploratory operation. Treatment. — Without entering into a discussion of the various methods which have been employed in the treatment of this con- dition in the past, it may be stated that at the present time the con- sensus of opinion among surgeons is that appendicular colic without fever, muscular rigidity, or leukocytosis can be safely treated by rest, an ice-bag, fasting, and an opiate if necessary, until the attack has subsided; to be followed in the interval by removal of the organ. ( 'atarrhal appendicitis which has passed the acuteness of the attack with a declining temperature, pulse rate, and leukocytosis, and with diminishing pain and tenderness, may also be treated in the same manner. All other cases should be operated upon as soon as the diagnosis is made, if the condition of the patient warrants the ad- ministration of an anesthetic and the surroundings are such as to admit of an aseptic operation with competent assistants. In interval cases the mortality following the operation should be less than 1 per cent.; in early acute cases when the inflammation is limited to the appendix the mortality should not exceed 2 or 3 per cent.; in abscess 564 DISEASES OF THE ABDOMEN cases, not greater than 5 per cent.; In cases with diffuse peritonitis the modern operative technic has caused great reduction in the mor- tality, but in late, neglected cases, with wide-spread peritonitis the prognosis is still very grave. In cases in which the conditions are such as to preclude the possi- bility of an operation, the treatment should be rest, ice, opium, and starvation, preceded, if possible, by evacuation of the stomach and bowels. These measures will serve to diminish peristalsis and favor subsidence of inflammation, or at least do away with the factors which tend to favor its rapid spread. Under no circumstances should cathartics be given to patients in whom there is a possibility of an acute appendicitis. The author believes cathartic medication to be responsible for early perforation in a large number of cases. Intermuscular Appendectomy (McBurney's Operation). — This is the simplest and safest operation on the appendix. It is indicated in all cases during the interval between the attacks, when there is no reason to expect serious adhesions or other complications which render a large opening necessary. It is also indicated in acute cases when the inflammation is limited to the appendix, and when the abdominal cavity can be tightly closed after removal of the disease. An incision two or three inches in length is made parallel with the fibres of the external oblique aponeurosis, the centre of which will lie a little to the outer side of McBurney's point. This divides the skin and subcutaneous tissues down to the aponeurosis. The apon- eurosis is then split in the direction of its fibres and well retracted, exposing the internal oblique, the fibres of which are next separated by blunt dissection and retracted in the opposite direction. The transversalis fibres can then be separated in the same manner, which exposes the thin transversalis fascia and subperitoneal fat. These structures are carefully divided 'and the peritoneum drawn upward in a transverse fold by two mouse-toothed forceps, and opened by the scissors or scalpel. The colon will generally be found immediately beneath this opening, and if one of its longitudinal bands is followed downward while the bowel is being drawn upward into the wound, it will be found to lead directly to the base of the appendix. In certain rare instances the colon will not be found in the iliac region. In these cases it will either be found in the right lumbar or hypochondriac region, due to an early attachment of the appendix and a failure of descent; or in the central zone of the abdomen, due to an incomplete rotation of the gut at an earlier period of development. If no adhesions exist, the appendix and cecum can be drawn outward through the wound, and the peritoneum protected by one or two small pads of gauze. The mesentery of the appendix is next ligated by passing a stout catgut ligature through its fold near the junction of the appendix with the cecum, and tying it well below the attachment of the mesen- tery to the appendix. If the mesentery is large, it should be ligated in sections. The appendix is next cut from its mesentery and held APPENDICITIS 565 upward by an assistant while the surgeon surrounds its base by a silk or fine chromicized catgut purse-string suture. When this is in place, the ends should be knotted, but not tied, and held by an assistant. The surgeon next applies two clamps just above the cecum, divides the appendix between the clamps, and cauterizes the stump, which is then inverted into the cecum by a pair of fine forceps grasping the cut margins and pushing them inward. During this maneuvre the assistant tightens the purse-string suture and the small forceps is withdrawn. By this method, which is known as the Dawbarn method, the stump is completely inverted and buried, leaving only a small puckered depression at the surface of the cecum. The method is the ideal one, and should be employed whenever possible. If, however, there is much infiltration of the cecum or appendix -which prevents its inversion without too much bruising, or if there exist dense adhesions which prevent the drawing upward of the cecum into the wound, the appendix should simply be ligated near its base w T ith chromicized catgut, divided with scissors, and the exposed mucous membrane treated by a drop of pure carbolic acid or the actual cautery. Before returning the bowel to the abdomen it should be touched with hydrogen peroxide and douched with salt solution. If there is reason to suppose that the peritoneal cavity has been contaminated, the wound should be well retracted and the surrounding intestines carefully wiped by moist gauze sponges or douched with sterile salt solution. The peritoneum is closed with a continuous catgut suture, the muscles allowed to fall together and held by one or two catgut inter- rupted stitches, the aponeurosis united in the same manner as the peritoneum, and the skin wound closed by two or three silkworm- gut or silk sutures. A small subcutaneous rubber tissue drain may be left for twenty-four or forty-eight hours if there has been con- tamination. If primary healing occurs, the patient may leave the bed on the eighth or ninth day. All authorities are practically unanimous in accepting the rule as regards early operation in acute cases seen within the first thirty- six or forty-eight hours. In a later stage of the inflammatory process, when perforative periappendicular abscess or peritonitis are present with signs of constitutional sepsis of greater or less degree, the condition apt to be found from the second to the fifth day, there is some differ- ence of opinion regarding the proper treatment. It is in this type that Ochsner insists strongly on his non-operative treatment, con- sisting in prohibition of fluids or food by mouth, or of catharsis, the employment of gastric lavage, saline solution by rectum, and rectal feeding. The majority of surgeons, however, believe that even in this class of cases, prompt removal of the appendix, with proper drainage, is the preferable procedure, provided the operation can be performed under proper surroundings by a skilled surgeon, and if modern principles of technic are employed, i. e., a minimum of trauma and exposure 566 DISEASES OF THE ABDOMEN of intra-abdominal contents, a quick operation, and adequate, but not excessive drainage. The choice of incision in this type of case is a matter of some differ- ence of opinion, the rectus, or Kammerer incision being preferred by some surgeons on account of better area of exposure; the intermuscular, or McBurney, by others because of the better drainage and lessened danger of spreading infection toward the central portions of the abdo- men. If the process is an abscess or localized peritonitis, great care must be taken to avoid spreading the infection in the peritoneal cavity. Gauze pads should be used sparingly, if at all, and never pushed through an infected area into clean peritoneum. Pus should be evacuated, a quick search made for the appendix, which is removed, if possible, without too much interference with protective adhesions. It is much better to leave the removal of the appendix to a second operation than to prolong the search too far or endanger the patient by severe trauma. When there are no limiting adhesions, and a more or less extensive diffuse peritonitis, quick removal of the appendix, with removal of the exudate with the least possible trauma, preferably by suction apparatus or by flushing with saline solution through a Chamberlin or Blake tube, with the insertion of cigarette drains to the region of the stump and often to the pelvis, should be the procedure. It is important to bear in mind, however, that the peritoneum is capa- ble of taking care of a considerable amount of exudate if the source of infection is removed and the peritoneal surfaces are not traumatized; also, that much of the cloudy serous exudate present in these cases is either sterile or very mildly infected. It is in this class of cases that the mortality has been so greatly reduced by a recognition of these principles. Chronic Appendicitis. — The course of chronic appendicitis shows many varieties: First, the recurrent type, with attacks of typical acute appendicitis of varying degrees of severity, chiefly, however, of the mild or moder- ately severe type, followed by intervals of complete freedom from pain, tenderness, or other symptoms, the free interval being of varying length. Second, a type similar to the first, except that in the interval be- tween the attacks, tenderness does not entirely disappear. In this type, the intervals of freedom from exacerbations are not apt to be so long, as persistent tenderness generally means retention of foreign material in the appendix. The third type is that in which there are no true exacerbations of the symptoms, but more or less persistent pain and tenderness, varying in severity from time to time, but never absent for any considerable period. The fourth type is spoken of as "appendicular dyspepsia" in which the symptoms are referred not to the appendix itself, but generally to the stomach, often with no pain or tenderness in the region of the appendix. APPENDICITIS 56' All types of chronic appendicitis are apt to be associated with constipation and more or less gastric indigestion. Postoperative Treatment. In interval cases and in early acute conditions when the abdomen is tightly closed, little postoperative interference is accessary if the ease progresses favorably. Morphine in small doses may be required during the first twenty-four hours to relieve pain. The bowels should be moved on the third or fourth day. For this small doses of calomel may be administered, followed by a saline draught, and enemata if necessary If much morphine has been used, there may be considerable diffi- culty in bringing about a movement, on account of the tendency to nausea which prevents the free use of salts. In these cases the frequent use of high enemata will generally be successful if there is no peritonitis. 1 If the pulse and temperature are normal, the dressing need not be changed for six or eight days. Obstinate vomiting after operation generally can be relieved by lavage, followed by absolute rest of the stomach, not even water being allowed. The practice of giving medicines to relieve postoperative vomiting is to be condemned, as they always serve to aggravate the condition. Continued pain and vomiting after operation point to peritoneal irritation; and if the pulse and temperature are elevated and the abdominal tenderness, rigidity and distension are increased, there is strong reason to suspect a spreading peritonitis. In these cases the wound may be reopened under anesthesia and the peritonitis treated as indicated above. Secondary operations for postoperative spreading peritonitis are rarely successful, however, and often it is wiser to carry out vigorous palliative treatment, repeated enemata, gastric lavage for vomiting, saline by rectum, hypodermoclysis, or infusion, rather than to reopen the abdomen. In acute cases in which drainage is employed, the wound should be inspected frequently and the outside dressings changed as often as they become saturated with the wound secretions. If the temperature and pulse remain elevated, and if tenderness and rigidity are present, the drains should be removed and any retained pus evacuated. Digital exploration of the wound with the gloved hand will often enable the surgeon to recognize a collection of pus by the induration, which may not be apparent on superficial abdominal palpation. Such deep-seated collections of pus are often drained best by rubber tubes until the acuteness of the symptoms has subsided. As soon as the sinuses 1 In a recent communication, entitled Catharsis in Abdominal Surgery, Dr. L. R. G. Crandon, of Boston, condemns the use of cathartic medicines by the mouth in cases of acute abdominal inflammation involving the alimentary canal. He advises high ene- mata both before and after operation. His best results were obtained by the use of the following formula: R- — Saturated solution of Epsom salt, Turpentine, Glycerin, aa §ij Water, 5vj — M. 568 DISEASES OF THE ABDOMEN are reasonably clean and granulations appear, further packing is unnecessary and only delays recovery. In the treatment of a generalized peritonitis the chief indications are to limit the amount of absorption from the peritoneal cavity and to promote rapid elimination. The former is best accomplished by placing the patient in the Fowler position (Fig. 28) to allow the septic material to gravitate toward the pelvis, where absorption is slow; the latter, by introducing into the system large quantities of fluid. At first reliance must be placed upon rectal salines, which should be given slowly at a temperature of 100° F., a short rectal nozzle being employed. Calomel should be administered as soon as the postanesthetic vomiting has ceased, followed by salines and high enemata. If the medicines are rejected by the stomach, it should be washed out and salts introduced through the stomach-tube. Enemata of turpentine, glycerin, 'and a saturated solution of Epsom salt should be given. When the rectum becomes intolerant, intravenous infusions are of the greatest value in stimulating the secretion of urine and inducing active diaphoresis. Cardiac stimulants, as strychnine, digitalis, caffeine, and alcohol, should be freely given. Sponge-baths and hot packs will often relieve the intense restlessness and high temperature. The practice of abandoning patients to their fate who develop general- ized peritonitis cannot be too strongly condemned. While the great majority of such patients eventually succumb in spite of all treatment, desperate cases occasionally are saved by energetic and persistent treatment. The author has recently seen such a patient recover after days of continuous vomiting of intestinal matter, enormous distension of the abdomen, a temperature of 108.5° F., and a pulse that could not be counted. In this case every available cutaneous vein in the body had been used for saline infusion. Localized abscesses in various parts of the abdominal cavity are not infrequent during convalescence from a diffuse peritonitis. Their presence is indicated by an acute rise in temperature and pulse, a high leukocytosis, pros- tration, and the occurrence of sweats. The tenderness may be slight even in large collections of pus, and should carefully be sought for by abdominal palpation, vaginal or rectal examination. The symp- toms will promptly subside as soon as the focus is located and adequately drained. Sequelae of Acute Appendicitis. — Infection from an inflamed ap- pendix may extend along the retroperitoneal lymphatics to the under surface of the diaphragm, giving rise to subphrenic abscess; or it may extend upward from the radicles of the portal vein to the liver, and as a result we may have a septic portal thrombosis with multiple ab- scesses of the liver and pyemia. Gerster and Munro have recently called attention to these conditions, which are not infrequent even after early operation and apparent subsidence of the septic manifes- tations. These complications would be favored by a rupture of the appendix and the formation or an abscess between the two layers of APPENDICITIS 509 its mesentery. The treatment of these conditions will be considered elsewhere. Fecal fistula not infrequently follows appendicitis, especially if the appendix and cecum are greatly infiltrated and surrounded by an abscess. In these cases removal of the appendix may result in injury to the wall of the gut, and a ligature placed around the stum}) may cut through before it is tightened sufficiently to occlude the lumen of the tube. Under these conditions a fistula often may be prevented by drawing a piece of omentum over the stump and suturing it to the cecal wall. The treatment of fecal fistula consists in cleanliness and frequent dressings. Drainage should be removed as soon as the sinus is sufficiently organized to remain patent, and the opening allowed to heal by granulation. The great majority of these cases heal spontaneously. - Ventral hernia frequently follows operations for acute appendi- citis, especially if the wound is allowed to remain open for drainage. The treatment is the same as for other varieties of postoperative ventral hernia. Congenital Idiopathic Dilatation of the Colon (Hirschsprung's Disease). — This rare condition, as the name implies, consists of a chronic dilatation of the sigmoid and often of the greater part of the transverse and descending portions of the colon, resulting in an enormous accumulation of fecal matter and gas (Fig. 286). The cause of the condition is by no means clear. Some authorities hold that it is due to a valvular obstruction in the upper part of the rectum. Others that it is due to some fault in the innervation of the gut, which results in a limited segment being without the power of peristalsis; while others ascribe the symptoms to an increase in the length of the sigmoid or its mesentery. Associated with the dilatation there is nearly always a decided thickening of the intestinal wall which involves all of the tunics. Symptoms. — Occasionally children are born with the condition already present. In the majority of instances, however, the symptoms appear shortly after birth. The cardinal symptoms of the condition are obstinate constipation and a progressive distension of the abdomen. The disease may ad- vance so slowly that many cases reach adolescence or adult life before serious symptoms develop. The distension is not always symmetric, being noticed more on the left side and lower half of the abdomen. The stools are often dry and hard; sometimes soft and very offensive. Movements occur at irregular intervals, and only after repeated enemata and catharitics. Visible peristalsis can sometimes be seen. There is, as a rule, no ascites. As a result of the interference with normal nutrition, the patients are thin, anemic, and weak. Dyspnea, cardiac weakness and irregularity are commonly observed when the distension is excessive and the diaphragm pushed upward. 571 1 hISEASES OF THE ABDOMEX Prognosis. —The disease is rarely fatal. In a few cases perforation has occurred with fatal peritonitis. The outlook for recovery, however, i> not good unless the condition can l»c removed by surgical operation. Treatment. While patients may he kept alive for an indefinite period by the judicious use of cathartics, enemata, massage, diet, and hygienic regulations, these have absolutely no effect on the patho- logic condition. Finney advises colostomy for the relief of the acute condition; later a lateral entero-enterostoiny above and below the Fig. 2s6. — Megacolon. distended portion, and at a still later period resection of the diseased area of the colon. Finney has recently reported a successful case operated upon by this method. DISEASES OF THE LIVER. Ectopic Liver. — The liver may be displaced downward in a condi- tion of general relaxation of the abdominal viscera (Glenard's disease). DISEASES OF THE LIVER .">71 Hepatopexy, or suturing the liver to the diaphragm or the abdominal wall, or shortening the relaxed ligaments, lias been advised to remedy this condition when it gives rise to sufficient discomfort to warrant surgical intervention, but the results are disappointing. Abscess of the Liver. — Abscess of the liver may arise from trauma; from infection carried to the organ by the hepatic artery in eases of genera] pyemia, by the portal vein from infections processes occur- ring in the regions drained by the portal system, as appendicitis, dysentery, typhoid fever, and other intra-abdominal or pelvic diseases; or from the biliary passages, as in cases of acute infective cholangitis. Hepatic abscesses may be single or multiple; the former are com- monly associated with dysentery, especially the amebic dysentery of the tropics, and in over 80 per cent, of the eases are situated in the right lobe. The^e amebic abscesses develop very slowly, and often are not recognized until months or years have elapsed since the colonic infection. Secondary infection may take place at any time and occasion a marked change in the clinical picture, by substituting an acute septic process for a slowly developing cold abscess. When mixed infection is absent, these abscesses cpntain a reddish or pinkish pns of thick gelatinous consistence. The ameba? are rarely found in the pus, but must be sought in the scrapings from the abscess wall. Another cause of solitary hepatic abscess is the infection by the blood current of a pre-existing hematoma of the liver, the result of some former* injury. Multiple abscesses more frequently follow appendicitis, suppuration of the biliary passages, or conditions of general sepsis. Large single abscesses may result from a coalescence of several smaller foci. They may reach an enormous size, and not infrequently rupture into the peritoneal or pleural cavity, into the lung, or into one of the hollow viscera. Symptoms. — The symptoms of hepatic abscess vary greatly, accord- ing to the virulence of the infecting agent and the presence or absence of a condition of general sepsis. In the large amebic abseesses the patient may complain only of a sense of discomfort and weight in the abdomen. Associated with this there are loss of flesh and strength and generally a moderate jaundice. The temperature may remain below 100° F., and the pulse, though weak, may not be rapid. In the majority of instances, however, there are pain and tenderness over the region of the liver, with fever, chills, and sweats. The patient rapidly emaciates and has the appearance of profound sepsis. The liver is enlarged and may be felt as an elastic tumor resembling a cyst. Unless there is a mixed infection, leukocytosis is not present in amebic abscess of the liver. In ab- scesses due to pyogenic bacteria the leukocyte count is often high. Rupture of the abscess into the peritoneum or pleural cavity would be followed by symptoms of inflammation of these structures. If rupture occurs into the lung-tissue, large quantities of pus may be expectorated; rupture into the intestine may be followed by rapid 572 DISEASES OF THE ABDOMEN relief of symptoms and ultimate recovery. In multiple abscesses of the liver arising either from portal infection or an acute ascending cholangitis, the symptoms are those of a grave and rapidly progressing general sepsis. Local symptoms and signs may be absent or there may be pain and tenderness over the hepatic region, with mild icterus. One of the most reliable signs is the occurrence of acute, deep-seated pain when the lower segment of the thorax is compressed. In these cases a fatal issue is to be expected in the great majority of instances. The use of an aspirating-needle for purposes of diagnosis is not to be recom- mended unless one is prepared to operate immediately if pus is found. In certain rare instances an abscess of the liver may give rise to no localizing symptoms or signs, the only evidence of disease being the presence of continued fever. Treatment. — A liver abscess may be opened and drained through the anterior abdominal wall or through the back by a transpleural operation. Both of these methods are dangerous and unsatisfactory unless adhesions are present. The presence of adhesions to the anterior abdominal wall would be indicated by edema of the skin and sub- cutaneous tissues. When this is present, an incision should be made through the tissues to the liver, which may then be aspirated, and if pus is found an opening into the abscess cavity can be made with the cautery or some blunt instrument and a drainage tube inserted. If •no adhesions are present, the abdomen should be opened over the en- larged Jiver, and if the symptoms are not too urgent, the parietal peritoneum may be stitched to the surface of the liver, the wound packed with gauze, and the opening into the abscess deferred until adhesions have formed shutting off the general peritoneal cavity. If the case is urgent and rupture is feared, the surrounding peritoneal cavity should be packed with large masses of gauze, the parietes pressed firmly down upon the surface of the liver, and the abscess cavity opened. The pus, if present in large amount, should be removed by means of a suction apparatus, the cavity disinfected with hydrogen peroxide and firmly packed with gauze, the end of which emerges through the abdominal incision. The abdominal packing is then removed and the wound partly closed, in the hope that, by the time it is necessary to remove the gauze from the abscess cavity, adhesions will have formed and contamination of the general cavity be avoided. If the abscess cavity is demonstrated by aspiration to lie posteriorly near the pleural sac, a portion of the eighth, ninth, or tenth rib may be resected, the parietal pleura stitched to the diaphragm, and the abscess opened immediately; or, if possible, the wound should be packed for forty-eight hours and the opening made after adhesions have formed. Mayo recommends, in suturing the parietal pleura to the diaphragm, that a few layers of sterile gauze be laid over the area to be sutured and the stitches taken through this pad. After adhesions have formed the incision is made directly through the gauze. In about GO per cent, of solitary abscesses of the liver the pus is sterile. In these TUMORS OF THE LIVER 573 cases the prognosis is favorable; in the more virulent cases the outlook is grave. There is no surgical treatment for multiple abscesses of the liver, except to open and drain the large collections as they are found. TUMORS OF THE LIVER. Hydatid Cysts. — These tumors occur more frequently in the liver than in any other organ of the body. They may be single or multiple, and may reach an enormous size. The fluid contained in a hydatid cyst is clear or slightly opalescent, of low specific gravity, contains a trace of salt but no albumin; scolices or hooklets can be found by the microscope. If the cysts are small and deeply seated in the liver, they produce no symptoms. If larger, they produce an enlargement of the organ and give rise chiefly to symptoms of pressure. If larger still and situated near the surface, the globular outline may often be made out and fluctuation sometimes determined. Hydatid fremitus oc- casionally may be detected by palpation if the cyst lies close to the abdominal wall. It is supposed to be caused by a rubbing together of the daughter cysts, and is appreciated by applying the palm of the hand to one part of the tumor and sharply percussing the mass at another point. It is rarely observed in cases where the amount of fluid is large. Santoni advises auscultatory percussion in these cases, and describes a characteristic sound of low, sonorous quality, which ceases abruptly. Thomas Fiaschi, of Sidney, Australia, whose ex- perience in hydatid disease is very large, has verified Santoni's ob- servation and regards this sound as of considerable diagnostic impor- tance. If suppuration occurs in one of the cysts, there will be pain, fever, chills, sweats, and prostration. Treatment. — Aspiration is to be avoided on account of the danger of infecting the peritoneal cavity; for it has been demonstrated that each of the parasitic elements is capable of reproducing the lesion. The disease may be treated in four ways: complete removal of the cyst with, if necessary, excision of a portion of the liver; emptying the cyst, removal of the endocyst, and stitching the ectocyst to the cutaneous margin (marsupialization) ; removal of the endocyst and closing the abdominal cavity, allowing the ectocyst to drain into the peritoneum; marsupialization, without removal of the endocyst, and the subsequent employment of solutions of formalin, nitrate of silver or iodine to render the sac and the remaining daughter cysts sterile. Quenu suggests aspiration of the cyst, and subsequent refilling with a 1 per cent, solution of formalin, which is allowed to remain for at least five minutes. This absolutely sterilizes the cyst contents, and allows the operation of removal to take place with less danger of peritoneal infection. Spontaneous recovery occasionally occurs from death of the organism. This may be favored, as suggested by Fiaschi, 574 DISEASES OF THE A EDO MEN by the internal administration of nrotropin. In these eases the cyst shrinks, and finally contains only a small mortar-like mass. Solid Tumors. — Angiomata, adenomata, sarcomata, and carcin- omata occur primarily in the liver. Small cavernous nevi are not infrequently found on autopsy. They give rise to no symptoms and are of no particular surgical interest. Adenomata may grow to the size of a small apple. They appear as greenish or whitish firm tumors, and rarely give rise to any symptoms or disturbance of function. Primary carcinoma of the liver, which is rare, may occur in two forms, one as a group of hard, whitish nodules, commonly situated in the neighborhood of the portal fissure; the other as a diffuse carcinomatous infiltration of the entire gland. Secondary carcinoma and sarcoma of the liver are of frequent occurrence, the former follows most frequently breast cancer, or disease situated in the portal area, the latter may result from sarcoma in any part of the body. While the diagnosis of primary malignant disease of the liver is rarely made at a period when operative treatment could hold out any prospect of cure or even justifiable palliation, it occasionally happens that an exploratory laparotomy will reveal the early stage of a malignant growth, situated in a favorable position for removal. Symptoms. — The symptoms of sarcoma or carcinoma are a marked but painless enlargement of the liver, which presents a hard nodular surface; jaundice, ascites, anemia, and progressive loss of flesh and strength. While malignant disease of the liver has, in the past, been regarded as an absolutely hopeless condition, the successful operations by Lin, Keen, Cullen, and many others have demonstrated that the resection of large areas of liver substance is not only technically possible, but is actually accomplished, with a comparatively low death- rate. This fact has encouraged surgeons to advise and practice removal in the early stage, of primary malignant growths of the liver, when located in an accessible position. The technic of the operation will be described later in the chapter. Gummata. — Gummata of the liver occur with considerable fre- quency. Although not a surgical condition, they give rise frequently to symptoms strongly suggesting surgical disease of the gall-bladder and ducts. These symptoms are pain, localized tenderness, and muscular rigidity in the upper right quadrant of the abdomen, with jaundice and occasionally the presence of a tumor. The author lias on three occasions opened the abdomen for treatment of a supposed cholecystitis, and found the lesion to be gumma of the liver; in one case more or less general, in two localized near the gall-bladder. In these doubtful cases the Wassermann reaction will be of posith e value. The Surgical Treatment of Ascites due to Cirrhosis of the Liver — The ascites of cirrhosis of the liver is generally believed to be due to obstruction of the portal circulation. Spontaneous cure has very rarely occurred, and in these cases a subsequent autopsy has demon- DISEASES OF THE BILIARY PASSAGES 575 strated adhesions and vascular connection between the liver, omentum, spleen, and intestines, and the diaphragm and anterior abdominal wall, allowing the blood from the portal system to gain entrance to the general circulation without passing through the contracted liver. Talma and Rutherford Morison each conceived the idea of favoring nature's methods in these cases by creating adhesions by surgical procedures. Morison's operation consists in making a median incision through the abdominal wall, opening the peritoneal cavity, and evacuating the fluid. The upper surface of the liver is then rubbed with a pledget of gauze until a raw bleeding surface is produced, and the adjacent surface of the diaphragm is treated in the same manner. The same procedure is next carried out on the external surface of the spleen and its adjacent parrietal peritoneum, after which the omentum is stitched to the anterior abdominal wall, the peritoneal surface of which has been similarly freshened. The abdominal wall is then sutured, and a glass drain introduced into the pelvic cavity through a separate incision just above the pubis, through which the accumulating fluid is removed by gauze suction three or four times a day until fluid ceases to be secreted. Morison obtained two cures of ascites by this method, and since that time several other favorable results have been obtained. A review 1 of all the cases reported in the journals during five years was made by the writer, which showed a mortality of 37 per cent., with 10 per cent, of cures and 20 per cent, of marked improvement. Greenough subsequently collected 105 operations which showed a death-rate of about 30 per cent, and less than 10 per cent, of cures. Xarath and others have modified the operation with a view to lowering the mortality. At present most surgeons simply evacuate the fluid, implant a portion of the omentum between the peritoneum and the rectus muscles, close the abdomen tightly, and depend upon sub- sequent tappings to remove the fluid which accumulates while the adhesions are being formed. The operative risk from this procedure is low. As experience has shown that these cases almost invariably die within a few months after the appearances of the ascites, the results of the operation would seem to warrant its continued trial. DISEASES OF THE BILIARY PASSAGES. Cholelithiasis. — Cholelithiasis, or the presence of gallstones in the biliary passages, is of frequent occurrence; according to Reidel and Kehr, they are found in 10 per cent, of all adult autopsies. Gall- stones are composed of crystals of cholesterin and lime salts, held together by mucus and colored by bile-pigment. They may occur singly or in any number. They may be rough, oval, or irregular 1 The Surgical Treatment of Ascites Due to Cirrhosis of the Liver, Medical News, February 8, 1902. 576 DISEASES OF THE ABDOMEN in outline, and of a dirty-brown color; or, more commonly, they are found to be smooth, faceted, and of a yellowish satin-like lustre. Two elements are essential for the formation of gallstones, stasis or a sluggish flow of bile, and infection. The former is brought about by a sedentary life, over indulgence in food, a relaxed abdominal wall, and obesity; the latter by some subacute infection, generally located in the portal area. Pathogenic organisms are carried from this focus to the liver by the portal vein, excreted in the bile, and thus enter the gall-bladder. Here they occasion a mild infection of the mucous membrane, giving rise to the secretion of a changed mucus which acts as a cement substance and binds the precipitated crystals of Fig. 287. — Radiograph of gallstones. cholesterin together. Exceptionally, biliary concrements may form in the bile ducts; these are generally softer, darker in color, lustreless, and appear to be composed of inspissated bile. The writer has once seen the gall-bladder and cystic duct completely filled with this material, which had the consistency of putty. Gallstones may occur at any age, but they are commonest in adults, and are more frequent in women than in men. Sedentary habits, overeating, and digestive disturbances act as predisposing factors. The frequent association of cholelithiasis with typhoid fever has led to much bacteriological investigation of gallstones. This has resulted in the demonstration in the calculi not only of typhoid bacilli, but of many other organisms mostly of the colon group. PLATE XIX Cholelithiasis with Cholecystitis. Lumiere plate of specimen taken from patient in author's service at the Roosevelt Hospital. DISEASES OF THE BILIARY PASSAGES 577 Symptoms. — Kehr stated some years ago that in 95 per cent, of the cases, gallstones produced no symptoms. At that time only the complication of cholelithiasis were recognized by their symptom- atology, for colic, fever, jaundice, tenderness and abscess formation are now known to be due to the transit of stones from the gall-bladder to the ducts or intestine, to biliary obstruction, or infection. That the presence of gallstones in an uninfected gall-bladder often can be recognized by a group of characteristic symptoms is now generally accepted. Moynihan has designated these as the "inaugural symptoms" of cholelithiasis. They differ entirely from those due to the passage of a stone to the intestine or its arrest in one of the ducts, and are largely digestive in character, often simulating mild cases of ulcer or the vague upper abdomen sensations of chronic appendicitis. Slight distress or fulness after meals, gas distension, and eructations are perhaps the earliest. Later epigastric pain, radiating to the back, pyrosis, transitory sensations of chilliness, especially after the evening meal, waves of slight nausea, and an occasional "catch in the breath" with a sharp stabbing pain at the costal border, are all more or less characteristic of cholelithiasis; and when associated with Murphy's sign or a sudden pain on inspiration when the thumb is pushed beneath the right costal arch at the outer border of the rectus muscle, they render the diagnosis of gallstones highly probable, although one would hardly be justified in making a more positive statement. When a gall-stone, of sufficient size to completely fill the cystic duct, begins its transit to the intestine, or when such a stone by tem- porary impaction causes a backing up of the bile and distension of the bladder, pain is produced of a severe colicky character, often radiating to the back and shoulder. This pain at times becomes so severe that morphine in large doses is required for its relief. With the pain often there is vomiting, localized tenderness, and great restlessness, but no fever. These attacks of gallstone colic often continue for several hours and then suddenly cease, due to the passage of the stone into the intestine or to the dropping back into the gall-bladder of a stone arrested at the beginning of the cystic duct. If the stone becomes per- manently impacted in the cystic duct, causing complete obstruction, the pain gradually subsides, and there follows a slow painless distention of the gall-bladder which is easily palpable (hydrops). These gall- bladders may reach a large size and are not infrequently mistaken for ovarian, hydatid, or other large abdominal cysts. The fluid contents in the later stages show r no trace of bile, only a thin cloudy or opalescent mucus. Sometimes the stone become arrested between two strictures in the cystic duct without marked obstruction. In these cases the attacks of colic occur frequently, often every day, are usually less severe and of shorter duration. There is no jaundice, and fever is rarely present. When a gallstone is arrested in the common duct, jaundice appears. The point at which stones usually become arrested is at the papilla 37 578 DISEASES OF THE ABDOMEN where the duct opens into the duodenum. Occasionally impaction at this point becomes permanent, when a progressively increasing jaundice occurs with a gradually lessening pain. The jaundice at first bright orange-yellow, gradually becomes darker, and as the cholemia advances the color may become green, brown, or almost black. The stools are clay-colored, the urine dark from the presence of bile, and a distressing itching of the skin is present. There is a rapid loss of flesh, and a tendency to intestinal hemorrhages. In the majority of cases, however, a common duct stone will remain impacted at the papilla for a short time only, then will be released by the resulting distension of the duct. This will allow it to pass into the intestine or to float upward in the dilated duct, with relief of all symptoms until it again becomes impacted at the papilla. This latter condition of "floating stone in the common duct" is associated with a very characteristic group of symptoms. There are intermittent pain, intermittent fever, and intermittent jaundice. Often the fever is high, and accompanied by chills and sweats; a condition somewhat resembling malaria, to which Charcot gave the name fievre inter- mittent hSpatique. The fever and other septic manifestations in these cases, is generally due to an infective cholangitis, the infectious material gaining entrance to the duct through the damaged papilla. Larger stones not infre- quently ulcerate through the gall-bladder or ducts, into the stomach or intestine, and may later become arrested in the bowel. This occasionally occurs without recognizable symptoms, and the first indication of the process may be signs of intestinal obstruction. One of the rarer complications of cholelithiasis is acute pancreatitis. This may be caused by the arrest of a small stone at the orifice of the papilla, allowing septic bile to regurgitate into the canal of Wirsung, giving rise to an acute suppurative or gangrenous pancreatitis. More frequently however, sepsis of a lower grade enters the pancreas by this route, or through the lymphatic connections of the pancreas with the biliary passages, which results in an edema, or chronic inter- stitial pancreatitis largely confined to the head of the organ. This by exciting pressure on the common duct may be the cause of continued jaundice, after the stone has passed or been removed. Of all the complications of cholelithiasis, the commonest is sepsis. This may occur in the gall-bladder, giving rise to cholecystitis of vary- ing degrees, or in the ducts causing cholangitis. These inflammatory conditions will be described at length in a subsequent section. Prognosis. — The presence of gallstones in the gall-bladder or ducts is undoubtedly a menace to the future health of the individual. While many individuals carry gallstones throughout a long life without apparent discomfort or serious consequences, complications are liable at any time to arise, placing health or life in jeopardy. All surgeons of experience recognize that removal of biliary calculi before infection occurs and before common duct obstruction is present, is a compara- DISEASES OF THE BILIARY PASSAGES 579 tively safe precautionary measure, and is to be advised when the condition of the patient's health and surroundings is favorable. Acute cholecystitis with the possibility of perforation, suppurative cholangitis, especially when complicated by cholemia, and suppurative or gangrenous pancreatitis, are serious conditions associated with a high mortality, and operations undertaken under these circumstances, are attended by grave risks. Treatment. — Cholelithiasis is a surgical disease. Medical treatment is of no avail except to palliate the distressing symptoms during an attack. A course at Carlsbad occasionally will relieve the catarrhal condition of the gall-bladder and ducts, but no known remedial agent has the power to dissolve gallstones. During an attack of colic, a hot bath, hot stupes, and morphine are indicated, and will often hasten the period of relief. Regular exercise, the avoidance of rich food and alcoholic drinks are of value as prophylactic measures, but when an individual once beings to suffer from gallstone disease, the surgeon should be consulted. Cholecyst ostomy with removal of stones is the operation of choice in cases of biliary calculi limited to the gall-bladder, when no infection is present and when the ducts are free. When cholecystitis is present or when the contractility of the gall-bladder has been lost as a result of former infection, when the cystic duct is strictured, or the seat of ulceration, which renders subsequent stricture and obstruction prob- able, cholecystectomy is to be advised. In cases of stone in the common duct, cholecodotomy with hepaticus drainage is indicated. When the stone is free in the duct or impacted in its upper segment, the incision can be made in its exposed area, above the head of the pancreas. In cases of impacted stone at or near the papilla, exposure of the duct by a turning inward of the duodenum may be necessary, or the transduodenal operation may be undertaken, removing the stone by an incision through the duodenal mucous membrane. In all these operations, especially in late neglected cases, a generous incision with plenty of light and adequate retraction is essential. Adhesions are frequently present rendering exposure of the parts difficult. In many instances adhesions between the gall-bladder and stomach and duodenum are the result of old fistulous openings, and care should be taken in dividing these, not to infect the operative area by leakage of infected bile or intestinal matter, before the wound area is adequately protected. Rough handling of the viscera in the upper abdomen is always associated with a high degree of shock. This is particularly dangerous in the obese, where the structures are deeply seated and difficult to expose, and where the individual resistance is low. Cholecystitis. — Infection may reach the biliary passages by several different routes. The commonest is by the portal circulation. Bacteria gaining entrance to the portal radicals from intestinal appendicular or pelvic infections, are carried to the liver. Here they are destroyed 580 DISEASES OF THE ABDOMEN by the bactericidal action of that organ when it is in its normal con- dition. If this important function is impaired by organic disease or the functional condition described as torpid or sluggish liver, many of these bacteria escape death and are excreted in the bile. Stasis or a sluggish flow of bile prevents the rapid elimination of these organisms from the gall-bladder and ducts, and if the resistance of these organs is still further reduced by the constant trauma of a foreign body as a gallstone, an infection results which may vary in intensity from the mildest catarrhal reaction of the mucous membrane, to an acute fulminating or gangrenous inflammation, involving all the structures of the gall-bladder or ducts. The second type of infection is the ascending. When the protective function of the sphincter at the intestinal orifice of the common duct has been impaired by overstretching from the passage of stones, or by ulceration or new growth, allowing regurgitation of the intestinal contents, infection may ascend along the ducts and enter the gall- bladder. The other and less frequent routes of infection are by the lymphatics, the arterial blood current, and by direct extension from a neighboring focus, as gastric or duodenal ulcer. Acute cholecystitis occurs in three clinical forms, the catarrhal, the suppurative and the gangrenous. The chronic type also occurs in three forms: the thickened, white, inelastic gall-bladder, the strawberry and the papillomatous varieties. The gross changes in the gall-bladder in cases of mild catarrhal inflammation are insignificent. "Where the process is more active the mucous membrane is thickened, the peritoneal coat loses its normal blue glistening appearance, and an excess of mucus is present in the bile. In the severer infections, the entire organ is thickened, red, edematous, and covered with fibrin. The mucous membrane is eroded and in places gangrenous, the bile is thick, tarry, and mixed with pus and mucus. In the severest types, gangrene and perforation may occur. In about 80 per cent, of these cases stones are present. In the chronic forms the appearances vary from a normal shaped gall-bladder with slight thickening, and opacity of the peritoneum, to a dense shrunken fibrous mass containing calculi and pus. In certain cases of chronic cholecystitis without stones, the external appearance of the organ is not changed, but the cavity is often found to be filled with dark colored foul smelling pus. In these cases a careful examination of the mucous membrane will reveal a reddened surface studded with innumerable yellow points, giving rise to the term "strawberry gall-bladder." The yellow points are minute bile-stained erosions on the summits of the papillae. In certain other cases there is a marked hyperplasia of the mucous membrane of the papillomatous type. MacCarty reports microscopic evidence in some of these cases of malignant disease. Symptoms. — The mildest types of catarrhal cholecystitis are symp- tomless, and are important, only in that they result in gallstone PLATE XX Acute Cholecystitis. Lumiere photograph of specimen taken from patient in author's service at the Roosevelt Hospital. DISEASES OF THE BILIARY PASSAGES 581 formation, and certain mild types of chronic thickening of the viscus. If the infecting organism is more virulent, it may be indicated by pain, tenderness, fever, and the presence of a tumor of the gall-bladder. In a mild infection of the organ with the ducts open, insuring free drainage into the bowel, these symptoms may be wanting. If the cystic duct becomes obstructed from stone or swelling of the mucous membrane, colicky pains occur, which may radiate to the back and shoulder; vomiting is generally present during the period of obstruction; there are also usually slight fever and general malaise, which disappear with the pain when the obstruction is relieved. Unless the gall-bladder be small or deeply seated under the right lobe of the liver, a sensitive tumor may be felt during the continuance of the obstruction. These symptoms frequently subside spontaneously, but the tendency to recurrence is marked. If chronic obstruction of the cystic duct occurs, empyema of the gall-bladder results, giving rise to symptoms of varying severity according to the virulence of the infecting agent to the resistance of the individual. The pain and fever may be wanting, the only symp- toms being the presence of a tender tumor in the gall-bladder region; or, in cases of a small or contracted gall-bladder, only a local tenderness or muscular rigidity. In the severer cases the pain is acute, paroxysmal, and radiating; the fever is high, and is accompanied by chills and vomiting. A local peritonitis may be present, a condition often resembling appendicitis. In the more virulent infections the symptoms often develop with great rapidity, and are accompanied by marked prostration and a rapidly developing sepsis. Perforation of the gall- bladder with a fulminating, fatal, septic, general peritonitis has been reported in a number of instances. Jaundice is absent in cholecystitis unless the tumor of the gall-bladder or an enlarged lymph node presses upon -the common duct. In chronic cholecystitis with or without stones, the symptoms may be simply the irregular occurrence of acute attacks, with no discomfort or only slight local tenderness between them, vague digestive disturb- ances, or simply the evidences of a mild chronic sepsis as a subacute arthritis. In these cases the gall-bladder on inspection and palpation often appears normal. On opening the viscus, however, changes in the character of the bile, and in the appearance of the mucous membrane are evident. Enlarged lymph nodes in the gastrohepatic omentum along the cystic and common ducts, easily palpable when the abdomen is opened, may often indicate the opening and investigation of a nor- mal appearing gall-bladder, in the presence of symptoms pointing to a chronic cholecystitis. Prognosis.- — Most cases of acute cholecystitis will subside under appropriate treatment, the pain, temperature, and other evidences of infection, showing a tendency to diminish at the end of twenty-four or forty-eight hours. A persistence of high fever, tenderness and muscular rigidity, and a progressively increasing leukocytosis, indicate 582 DISEASES OF THE ABDOMEN a suppurative or gangrenous cholecystitis or an extension of the process to the surrounding tissues. Chronic thickened gall-bladders are a menace to the individual, and should be removed, particularly if the cystic duct is strictured or occluded. The strawberry gall-bladder is frequently the source of a chronic sepsis which is not permanently relieved by drainage. The papillomatous type of chronic cholecystitis, occasionally results in cancer. Treatment. — Mild cases of cholecystitis should be treated by rest and an ice-bag to the tender region of the abdomen. If the pain is severe, it may be necessary to relieve it by the use of morphine or other forms of opium. Although the gall-bladder seldom ruptures spon- taneously, infection of the peritoneal cavity may rarely occur without rupture and lead to a spreading peritonitis and grave sepsis. For this reason operative treatment is indicated if the symptoms do not promptly subside as a result of the treatment outlined above. If the cholecystitis is acute and the ducts are patent, cholecystostomy will give prompt relief; if the condition is a chronic, relapsing one with an occluded cystic duct, and a shrunken, functionless gall- bladder, cholecystectomy is to be recommended. In the strawberry and papillomatous types of chronic cholecystitis, cholecystectomy is indicated. Cholangitis. — An inflammation of the mucous membrane of the bile ducts, particularly of the common and hepatic. In the acute type which is practically always associated with the presence of stone or some other foreign body as an intestinal worm, the infection "is often a virulent one, extending rapidly to the intra- hepatic branches giving rise to multiple abscesses and a fatal toxemia. In other cases the process seems to be limited to the larger ducts, and although marked evidence of septic absorption may be present, especially when drainage into the intestine is interfered with, the condition may exist for months or years without the development of fatal hepatic lesions. An exceedingly mild type of the affection is often described, which is thought to be an ascending process from the duodenum without known cause, or the presence of any pathological process in the gall- bladder or ducts. This subacute cholangitis is supposed to be the cause of the so-called "catarrhal jaundice." As the association of this lesion with transitory, afebrile and symp- tomless jaundice has not been demonstrated, the majority of surgeons now accept the view of Robson that the causation of most cases of catarrhal jaundice is to be found in a temporary closure of the common duct from the pressure of a lymphatic edema or subacute inflammation of the head of the pancreas. Symptoms. — Acute cholangitis occurs most frequently in cases of common duct stone, particularly in the type described as floating stone. These cases present a very characteristic group of symptoms. TUMORS OF THE GALL-BLADDER AND DUCTS 583 When duct occlusion occurs from temporary impaction of the stone, at the papilla, there will occur a chill followed by high fever, colic, increased jaundice, and often sweating. All of these symptoms are relieved when the stone floats upward and drainage is established. These attacks occur at irregular intervals and their duration is gener- ally short. When the period of obstruction is of longer duration, or when the virulence of the infection is high, the type of symptoms changes to that of a rap'dly advancing septic intoxication, continued high fever, chills, a rapid feeble pulse, high leukocytosis with pro- gressive jaundice, prostration, delirium, and death. In certain rare cases the attacks occur at longer intervals, several days or weeks may elapse during which the patient is free from all symptoms or discomfort. In these cases the condition may exist for many months or even years, the patient gradually deteriorating in health and presenting the evidences of chronic invalidism. Prognosis. — The prognosis in acute septic cholangitis is grave. In the more virulent cases the course is rapid toward a fatal termination unless promptly relieved by operation. In the less virulent cases, the outlook is also serious, for the possibility of relief by the spontaneous passage of the stone is exceedingly remote, and until adequate drainage is secured permanent improvement is not to be expected. Treatment. — As soon as the diagnosis of acute septic cholangitis is made, the indications are for operation. Choledochotomy, removal of the stone, and hepaticus drainage. TUMORS OF THE GALL-BLADDER AND DUCTS. While new growths of neighboring organs not infrequently produce symptoms referable to the gall-bladder or ducts by external press- ure or direct extension, primary new growths in these organs are exceedingly rare. The gall-bladder is most frequently affected, and in the great majority of instances the growth is malignant. Carcinoma of the Gall-bladder was observed, according to Cour- voisier, in 7 in 2520 autopsies. Three-fourths of the cases occur in women. The relationship between cholelithiasis and cancer of the gall-bladder is evidenced by the fact that in 95 per cent, of primary cancer cases stones are present, while in the secondary carcinomata of this organ calculi are found in only 15 per cent. As in the case of ulcer of the stomach, chronic irritation gives rise to an inflammatory process with epithelial proliferation which eventually results in cancer. MacCarty of the Mayo Clinic has recently published the report of some pathological studies in these cases, and has been able to obtain convincing evidence of the fact that chronic papillomatous colecystitis not infrequently degenerates into cancer. Symptoms. — There are no early characteristic symptoms of gall- bladder cancer. Symptoms and signs of stone or the associated 584 DISEASES OF THE ABDOMEN cholecystitis may or may not be present, and not infrequently vague digestive disturbances, and loss of weight and strength may be noted before any signs of the disease are manifest. Tumor, in the great majority of cases, is the first sign, and is often discovered by accident or as a result of a systematic abdominal examination. Later there may be pain, vomiting, anorexia, and jaundice. This last symptom with ascites and splenic enlargement, are to be regarded as terminal symp- toms and are due to the pressure of involved lymph nodes on the portal vein and common duct. Prognosis. — The outlook in cases of gall-bladder cancer is exceed- ingly grave, hopeless in fact, if operation is not undertaken until the diagnosis is made probable by the clinical signs. In 53 such cases operated upon, death followed in every instance within nine months (Courvoisier). In cases discovered at an earlier period, as a result of an exploratory laparotomy, the prognosis is more favorable, two out of five such cases were reported from the Mayo Clinic to be alive, and free from recurrence at the end of two years. Tumors of the Bile Ducts. — Both benign and malignant tumors occur in the gall ducts. Carcinoma.— Carcinoma of the ducts is a rare disease. About one case to six of cancer of the gall-bladder; or once in 2300 autopsies according to Kelynac. Its commonest seat is in the common duct, at or near the papilla. It is equally frequent in males and females indicating that cholelithiasis is less important as a causative factor, than in carcinoma of the gall-bladder. The symptoms of this condition are those of a gradually increasing closure of the common duct, progressive jaundice without pain, and the gradual development of asthenia, anemia, and loss of weight. Cholemic itching and a tendency to hemorrhage are present in the later stages. In these cases, as in all other cases of common duct obstruction from new growth, there will occur an enlargement of the gall-bladder from a backing up of the bile. This does not occur in the majority of instances where the obstruction is due to an impacted calculus, a fact to which Courvoisier called attention many years ago. Benign tumors of the duct give rise to no symptoms unless they cause stenosis. When this occurs the symptoms are those of progres- sive jaundice, but without the rapid cachectic wasting of cancer. Exceptionally the jaundice may be intermittent, due, as in a case reported by Courvoisier, to a small pedunculated tumor near the papilla which acted as a ball valve. Common duct obstruction from the outside pressure of a carcinoma of the head of the pancreas, from an extension to the ducts of a pyloric cancer, from the enlarged lymph nodes of cancer metastasis or Hodgkins disease, or from a chronic interstitial pancreatitis, will all result in the occurrence of a progressive painless afebrile jaundice, simulating cancer of the ducts. In many of these cases a positive diagnosis ran only be made by exploratory operation. OPERATIONS ON LIVER, GALL-BLADDER, AND DUCTS 585 The prognosis in duct cancer is bad. A few cases of cancer of the papilla have been operated upon with success, but the author knows of no instance of cancer in other portions of the duct being cured by operation. Treatment. — Carcinoma of the gall-bladder, if discovered early, should be completely removed by cholecystectomy, including a considerable area of the underlying liver, if this is at all involved. Benign tumors of the ducts occasionally may be removed surgically. Carcinoma of the common bile duct, when small and situated at or near the papilla can be removed by a transduodenal operation. In rare instances, when a small tumor of the common duct above the papella is discovered on exploratory operation to be in an accessible position, it can be removed by excision of the diseased area, followed by an end-to-end anastomosis or by implantation of the proximal extremity of the duct into the duodenum. More advanced cases of duct cancer and inoperable tumors of other organs producing per- manent occlusion of the common duct may be treated palliatively by cholecystenterostomy or anastomosing of the gall-bladder to the duodenum, jejunum, or colon. The immediate mortality in these palliative operations is high and the measure of relief often small, and for that reason most conservative surgeons are inclined to advise against operation in all cases of advanced malignant disease of these organs. OPERATIONS ON THE LIVER, GALL BLADDER, AND DUCTS. Resection of the Liver. — This operation is undertaken for the removal of primary malignant growths, small echinococcus cysts, or hopelessly injured areas. It is generally advisable to remove a triangular area, the base of which corresponds with the free edge. Two long-bladed stomach or intestinal clamps are applied just beyond the area to be removed. The clamps should have moderately flexible blades covered with rubber tubing to prevent injury to the liver tissue. After application of the clamps the pathologic area is excised with a scalpel and the visible bloodvessels clamped and ligated. Several deep mattress sutures are then passed, about one inch from the incised border, and, after removal of the clamps, the cut edges are pressed together and the mattress sutures tied. In passing the sutures only a blunt needle should be employed, and the suture material should be heavy, plain catgut. If no bleeding occurs, the peritoneal cavity may be closed without drainage. Cholecystotomy. — Cholecystotomy consists in opening the gall- bladder for purposes of exploration or for the removal of a foreign body. The abdomen should be opened by a longitudinal incision near the outer border of the right rectus muscle, extending from the carti- lage of the eighth rib to a point opposite the umbilicus. The gall- bladder is drawn upward into the wound and the peritoneum protected 586 DISEASES OF THE ABDOMEN by gauze pads. An incision is made in the fundus, and the foreign body removed, after which the opening is closed with two rows of Lembert sutures, the parts disinfected, and the gall-bladder returned to the abdominal cavity, which is closed by layer suture. Cholecystostomy. — In cholecystostomy for drainage of the gall- bladder, the viscus is exposed as in cholecystotomy. Two circular purse-string sutures are introduced into the peritoneal covering of the fundus of the gall-bladder, the first making a circle about one-third inch in diameter, the second surrounding the first and about one-third inch from it. An incision is then made within the inner circle and a rubber drainage tube introduced. As the tube is being passed into the bladder the first suture is tightened and knotted; the tube is then pushed further inward, carrying with it a funnel-like depression of the fundus, as the second suture is tied. The abdominal wound is then partly closed and the gall-bladder attached to the parietal peri- toneum by one or two catgut sutures. The advantage of this method is that after the wound has healed there is practically no leakage when the tube is removed, and a permanent and lasting fistula is thereby avoided. This method may be carried out even after large incisions in the gall-bladder for the removal of stones, etc., by the introduction of a few more sutures. Cholecystectomy. — In this operation the gall-bladder is exposed as in the other operations, the cystic duct located, freed from its peritoneal coverings, and double ligated with silk or heavy chromicized catgut. The cystic artery, which lies to the inner side of the duct, should then be exposed and tied. The gall-bladder is next separated from the under surface of the liver by blunt dissection, after first incising its peritoneal covering at its junction with the liver. When the gall- bladder is thoroughly separated from the liver the cystic duct is divided between the two ligatures and the organ removed. Hemorrhage should be arrested by ligating any bleeding points and by gauze packing pressed against the raw surface of the liver. After all bleeding has been controlled, any raw surfaces may be covered by suturing over them a portion of the round ligament or omentum. This is an impor- tant part of the operation, as it may prevent the occurrence of trou- blesome stenosing adhesions. The abdominal wound is then partly closed, leaving a cigarette drain which should extend to Morison's pouch. Choledochotomy. — In choledochotomy, or opening one of the bile- ducts for the removal of a stone or for drainage, a large abdominal incision should be made through the right rectus muscle, extending as high as possible. If the abdominal wall is thick, the S-shaped incision of Bevan will give an excellent exposure. It is made by adding an oblique inward cut to the upper, and an oblique outward cut to the lower end of the regular straight rectus incision. When the gall- bladder region is freely exposed and the intestines well walled off by OPERATIONS ON LIVER, GALL-BLADDER, AND DUCTS 587 large masses of handkerchief gauze, the operator introduces his left hand deeply into the wound and carries the index finger into the lesser peritoneal sac through the foramen of Winslow. With the forefinger in the foramen and the thumb above the free edge of the lesser omen- tum, the hepatic, cystic, and common ducts may easily be palpated as far as the pancreas. If a stone is detected, the duct is raised with the underlying finger, and brought as near the surface wound as possible. The stone is recognized, and after the duct is freely exposed by removal of the peritoneal covering it is incised longitudinally and the stone removed. A probe should then be passed upward and down- ward to insure patency of the remaining portions of the duct. Occa- sionally it may be impossible to determine by the probe whether the duct contains more stones or not. If the duct is sufficiently dilated this question can easily be settled by digital exploration; if not, careful external palpation through the walls of the duodenum, and over the head of the pancreas may enable one to detect the presence of a stone in the lower part of the duct or ampulla of Vater. It must be admitted, however, that in certain rare instances this point cannot be absolutely determined by any safe procedure. Closure of the duct wound should never be complete where stone has been found, for a certain amount of infection seems always to be present. If the evidences of duct infection are slight, closure may be effected by a few interrupted sutures, leaving sufficient space between them to insure drainage if any back pressure or obstruction to the outward flow of bile into the intestine occurs. A large cigarette drain should then be carried down to the line of suture. In the great majority of instances it is wiser to introduce hepaticus drainage by means of a rubber tube. It should be introduced into the hepatic portion of the duct and held in place by a single catgut suture. This should be accompanied by a cigarette drain to the region of the duct, and if much infection is present, a second to Morison's pouch. The cigarette drain can be removed at the end of forty-eight hours, the tube should be left in place con- siderably longer. Transduodenal Choledochotomy. — Duodenotomy, for removal of a stone in the lower third of the common duct, has been recommended by McBurney as an easier and safer method than by exposing the duct at this part. An incision is made in the second portion of the duodenum, parallel with the long axis of the bowel, the position of the stone recognized by palpation and inspection, and its removal effected by an incision through the mucous membrane into the diverticulum of Vater or the duct. The external duodenal wound is then closed by two rows of Lembert sutures, the surrounding parts carefully disinfected, and the abdominal wound partly closed with drainage. Cholecystenterostomy. — This operation occasionally is indicated in cases of inoperable, complete, and permanent obstruction of the com- mon duct and in certain cases of biliary fistula. When possible, the fundus of the gall-bladder is anastomosed to the second portion of the ."vs DISEASES OF THE ABDOMEN duodenum. When this is impossible on account of adhesions, or a misplaced or small gall-bladder, union with the stomach, the jejunum, or even with the hepatic flexure of the colon, may be made. The best method of effecting this anastomosis is by the use of a small Murphy button, the technic of which has already been described. After the two halves of the button have been joined the line of union may be protected and strengthened by wrapping it with a mass of omentum and securing it in place by two or three catgut sutures. In all operations upon the bile ducts it should be remembered that elevation of the upper lumbar region by means of the adjustable kidney rack of the modern operating table or by a pad or cushion, placed beneath the lower dorsal region, will increase to a considerable extent the exposure of the part-. DISEASES OF THE PANCREAS. Among the congenital malformations of the pancreas may be mentioned the rare instances of complete absence of the organ; acces- sory glandular masses located above or below the pancreas generally near the head; the annular pancreas completely surrounding the duodenum, and the small aberrant nodules occasionally found in the walls of the duodenum. These anomalies are of no surgical importance, but the possibilitv of their occurrence should be remembered, as they are not infrequently mistaken for new growths. Pancreatitis. — Infection may reach the pancreas by means of a penetrating wound, as in a gunshot or stab injury of the abdomen; by the blood current, as in mumps and other infectious diseases; by an ascending infection along the duct, often brought about by the regurgitation of infected bile when the duodenal orifice of the diverticu- lum of Vater is closed by a calculus or new growth; by the lymphatics, in gall-bladder or duct infections, or from lesions of the stomach, duodenum, or vermiform appendix; and by direct extension of an inflammatory process from some adjacent organ or tissue. Various theories have been suggested to account for the sequence of events, which takes place when the pancreas is the seat of a virulent infection. The first is that infection in the gland produces a chemical substance or kinase, which activates the tripsinogen of the pancreatic juice producing trypsin. This in turn causes a digestion of proteid material resulting in necrosis and hemorrhage. Another theory is that toxic agents in the blood produce hemorrhagins which cause a necrosis of the endothelium of the bloodvessels giving rise to single or multiple hemorrhages. Opie has demonstrated that simple regurgi- tation of bile into the canal of Wirsung in animals, is capable of pro- ducing an acute pancreatitis. The frequent association of pancreatitis with cholelithiasis and infection of the biliary passages, led to the early belief that the majority of cases of acute pancreatitis were due to regurgitation of infected bile; but of late the tendency has been to DISEASES OF THE PANCREAS 589 look upon the extension of infection from the biliary passages by the lymphatic route as more common. A study of the lymphatic arrangement of the pancreas, gall-bladder and ducts, duodenum, and the stomach, will show that there is a very free anastomosis between the lymph channels of all of these structures ; and in an acute infection in any of these organs, with blocking of one or more of the larger lymph channels, a reversed current of the lymph stream might easily carry infection to the pancreas. Whatever the source of infection, the most important factor in acute pancreatitis is the escape of pancreatic fluid from the duct or its radicals into the parenchyma of the gland or the surrounding areolar tissue and fat. This by its fat-splitting ferment gives rise to a more or less extensive fat necrosis, opening .up larger bloodvessels and furnishing a favorable soil for the rapid extension of the infective process. As a result we may have, early in the disease, an extensive hemorrhage in the gland or escaping into the lesser peritoneal cavity, pancreatic apoplexy or hemorrhagic pancreatitis; single or multiple abscesses, or a diffuse suppuration of the entire gland and the surrounding fat, suppurative pancreatitis; or more or less extensive areas of necrosis, gangrenous pancreatitis. With all of these types of the disease, if the process continues, there will occur a bloody peritoneal exudate which is highly toxic; also multiple small areas of fat necrosis in the omentum, mesen- tary, and subperitoneal fatty tissues. Occasionally the pancreatic ferments are carried by the blood and lymph currents to remote parts of the body, giving rise to fat necrosis and hemorrhages in other organs and tissues. In the subacute cases, the infection being less virulent, or the resistance of the individual greater, the resulting pancreatic changes are found chiefly to be hyperemia, edema, or occasionally a single slowly forming abscess. In these cases the disease generally is limited to the head of the gland, although solitary abscesses of the body and tail occasionally are encountered. In chronic pancreatitis the pathological changes are chiefly repre- sented by an overgrowth of connective tissue, which results in a hardening of the gland and a pressure atrophy of the secreting elements. This in the majority of instances occurs in the head and body. Acute Pancreatitis. — The disease was first accurately described by Fitz in 1899. He called attention to the fact that it presented three distinct clinical types; the hemorrhagic, the suppurative, and the gangrenous. Since that time a great deal of attention has been given to the subject both by pathologists and clinicians, and many additional facts have been collected regarding its etiology and clinical history. It is now generally conceded that the disease is essentially a surgical condition, as operation furnishes the only means of successfully meeting the indications in any of its severer types. It has also been observed that the three types described, by Fitz are often associated. It is rare in childhood, and occurs most frequently in adults over fort}' 590 DISEASES OF TEE ABDOMEN years of age. It is slightly more common in men. In a large number of instances its victims have suffered from cholelithiasis or infection of the biliary passages. Obesity is frequently spoken of as a predis- posing cause, and in some rare instances, trauma undoubtedly is an etiologic factor. The disease in its acuter forms, is often rapidly fatal in spite of prompt and rational treatment. Symptoms. — The symptoms of an acute pancreatitis are characterized by suddenness and intensity. There is severe epigastric pain with symptoms of collapse, as pallor, cold extremities, restlessness, perspira- tion, subnormal temperature, and a rapid feeble pulse. The abdomen at first is retracted, and the muscles rigid. Vomiting occurs in the majority of cases, with hiccough, and later dyspnea from interference with the free action of the diaphragm. All of these symptoms may progress rapidly and death may take place in a few hours. Generally, however, there is a slight rally after the first few hours of intense suffering, and symptoms of a local or spreading peritonitis supervene. The abdomen gradually becomes distended, the muscular rigidity more extended, and signs of fluid in the greater peritoneal cavity are manifest. The temperature rises, a leukocytosis develops, the vomit- ing continues, and signs of an advancing paralytic ileus occur. Cases seen in this stage are not infrequently mistaken for acute mechanical obstruction of the bowel. In less severe cases the signs of peritonitis may be limited to the epigastric region. In these instances, the local process results in abscess, often limited to the lesser peritoneal sac, which eventually points in the left flank. In other cases pus may burrow upward forming a subphrenic collection, or it may approach the surface high up between the stomach and liver, or between the stomach and transverse colon. In these cases the inflammatory exudate easily can be palpated through the abdominal wall. In many of these abscess cases a more or less extensive slough of the pancreas or surrounding fat is found at operation or autopsy. As these cases, in the early stage, often simulate rupture of a gastric ulcer, and later resemble acute intestinal obstruction, an exact diagnosis often is impossible without an exploratory incision. As soon as the abdomen is opened, the diagnosis is confirmed by the presence of a bloody serous exudate, and by numerous small white subperitoneal areas of fat necrosis in the omentum, mesentary and upon the intestine. Treatment. — Except in the milder cases which do not present evi- dences of severe shock, and in which improvement rapidly follows rest and expectant treatment, all cases of possible acute pancreatitis should be subjected to operative treatment unless the shock or general sepsis is such as to preclude the possibility of administering a general anesthetic. Even in these cases an exploratory incision under cocaine may be undertaken. The abdomen should be opened in the median line above the umbilicus, and the pancreas exposed by tearing through the greater or lesser omentum. Clots or gangrenous masses, if present, should be removed; hemorrhage arrested by ligature or gauze packing; DISEASES OF THE PANCREAS 591 localized collections of pus opened, disinfected with hydrogen peroxide and packed; larger areas of suppuration treated as intra-abdominal abscesses from other causes. If possible, deep-seated suppuration should be drained through the back. Owing to the anatomic arrange- ment of the connective-tissue planes about the pancreas, suppuration in this region tends to burrow toward the left flank, and should there- fore be drained in this region. In certain early cases the pancreas may simply appear acutely inflamed and edematous. In these, incisions should be made through the capsule and gauze drainage employed. At a later period gangrenous areas separate and should be removed. In all cases the blood stained highly toxic peritoneal exudate should be removed. The disease, unless treated surgically in the earlier stages, is. an exceedingly fatal one. This, however, should not deter the surgeon from operating late, as brilliant results are occasionally achieved by thorough operation and energetic post- operative stimulation. Prognosis. — Severe cases of acute pancreatitis, as described above, are almost always fatal without operation. Undoubtedly a few of the milder cases presenting acute symptoms for a few hours only, and then showing rapid improvement, may recover spontaneously. When operation is undertaken early in the disease, and carried out without too much trauma and shock, the outlook is favorable, for so grave a condition, as upwards of 50 per cent, of the cases may be saved. In the milder abscess cases, seen late, the prognosis is still more favorable. Subacute Pancreatitis. — In very mild and non-suppurative infections of the head of the pancreas, we have an entirely different clinical picture. Often there is no pain, no fever, and no tenderness; the only symptom being obstruction of the common duct, producing the so-called " catarrhal jaundice." In other cases there may be moderate pain and tenderness for a few days, with or without a slight rise in temperature. There is anorexia, sometimes nausea and vomiting; jaundice may or may not be present. These symptoms generally subside with rest in bed and attention to diet, but occasionally they may recur when the patient is again up and about. In two such instances the writer was at a loss to account for the recurrence of symptoms after an apparent cure. In each case, however, as a result of a careful physical examination, a definite, local point of tenderness was found, in one instance over the head of the gland, in the other to the left of the spine. Later these cases were explored, and in each instance, a small circumscribed abscess was found at the point of tenderness. In the first case there was moderate fever at the time of operation; in the other there had been no fever for two or more weeks, only pain and nausea, w T hen the patient attempted to leave the bed. These cases have been extensively studied by Deaver, who believes them to be due often to the extension of a mild infection from the biliary passages, stomach, or duodenum, by means of the 592 DISEASES OF THE ABDOMEN lymphatics, pancreatic lymphangitis. As the common bile duct is com- pletely surrounded by the head of the pancreas in over 60 per cent, of the cases, it is easy to appreciate that an inflammatory exudate or even a simple lymphedema of the head of the pancreas, might exert sufficient pressure on the duct to give rise to a temporary obstruction. It is probable that a mild degree of pancreatitis is present in many cases of neighboring infection, but unless the infec- tion is of sufficient intensity to give rise to a febrile reaction, pain or toxemia; and unless the common duct is occluded by the surrounding outside pressure, no symptoms are produced. Deaver has expressed the opinion that these mild symptomless attacks of lymphangitis of the head of the pancreas, may represent the early stage of the chronic interstitial pancreatitis to be described in the next section. As the majority of these cases subside spontaneously, the only opportunity of verifying their presence is during an operation for cholelithiasis, or infection of the gall-bladder or ducts. In these instances one may easily palpate the head of the pancreas by the finger introduced into the lesser sac through the foramen of Winslow. When subacute pancreatitis of the head of the gland is present, the finger will easily detect the swelling, increased density, and edema of the gland. Enlarged lymph nodes about the head of the gland and along the bile ducts, generally accompany this condition. Removal of the original focus of infection and drainage of the biliary passages, frequently hastens resolution of the pancreatic lesion. Chronic Pancreatitis. — Chronic pancreatitis is usually an interstitial inflammation resulting in a localized or general cirrhosis of the gland, due generally to a long-continued infection of the canal of Wirsung and its branches, or as Deaver suggests to a late stage of a subacute lymphagitis. In 79 cases reported by this author, 72 presented evidences of previous infection of the biliary passages. Opie describes two types, the interlobular and the interacinar. Both give rise to an overgrowth of the connective tissue of the gland; but the latter, by a gradual pressure atrophy of the islands of Langerhans, causes diabetes. The interlobular type, which is the commonest, occurs generally in the head of the pancreas, but may occur in any other part of the gland, and is characterized by a general hardening of the tissues without enlargement. The condition has been extensively studied by Kehr, Moynihan, and Mayo-Robson, who recognize in it one of the causes of chronic obstructive jaundice. Symptoms. — The disease, as a rule, gives rise to no pain or sign of inflammation. Usually there is a history of cholelithiasis or of several slight attacks of pain and tenderness in the epigastric region. When the head of the pancreas is the seat of the lesion, the two chief symptoms are progressive loss of weight and jaundice. The former is always present, the latter occurs in about 60 per cent, of the cases, which is practically the percentage of cases in which the common duct is sur- TUMORS OF THE PANCREAS 593 rounded by pancreatic tissue. As these symptoms are also the chief symptoms of early carcinoma of the head of the pancreas, a differential diagnosis between the two conditions is often impossible, even after an exploratory operation, as in each there is a hard, easily palpable fixed tumor behind the pylorus in the concavity of the duodenum. As in other cases of complete obstruction of the bile and pancreatic ducts, the stools are large, clay colored, contain undigested meat fibres, and often appear opalescent from the presence of fat. The urine is concentrated and highly colored from the contained bile. Glycosuria occasionally is observed. Robson and Moyniban have recently called attention to the Cammidge reaction of the urine as an important aid to diagnosis in chronic pancreatitis. For a description of the technic of this test the reader is referred to the original paper by Cammidge. 1 Moynihan also states that in his experience the jaundice of chronic pancreatitis is a lighter yellow than in carcinoma. In the latter condition the color is deeper and presents a more greenish hue. Treatment. — The curative effect of cholecystenterostomy and of simple cholecystostomy has been demonstrated in a number of cases reported by Robson and others. On account of the difficulties and frequent errors in diagnosis, all cases of chronic obstructive jaundice should be given the benefit of one of these procedures, if there is a reasonable chance that the disease is not malignant. TUMORS OF THE PANCREAS. Carcinoma. — Primary carcinoma of the pancreas is occasionally encountered, and when present generally affects the head of the gland. The organ is more frequently involved secondarily as a result of extension of the disease from the stomach or some other neighboring structure. Symptoms. — The symptoms of this condition are a progressive loss of weight and strength, accompanied or followed by jaundice and intense itching of the skin. The jaundice is similar in its behavior to other varieties of jaundice caused by a complete and permanent obstruction of the common ducts in that it is progressive, without remissions, and is unaccompanied by colic. Digestive disturbances are always present in the disease, and are of the pancreatic type; steatorrhea, azotorrhea, and an absence of stercobilin in the feces. Diagnosis. — The diagnosis of carcinoma of the head of the pancreas is not always clear. In the presence of a progressively increasing jaundice with loss of flesh and strength, one must consider three conditions — an impacted stone in the common duct, chronic interstitial pancreatitis, and carcinoma. Stone would be indicated by a previous history of biliary colic, with or without attacks of transitory jaundice, by the occurrence of pain at the beginning of the present attack, and by the 1 Lancet, March 19, 1904. 38 594 DISEASES OF THE ABDOMEN absence of a gall-bladder tumor. Chronic pancreatitis, on the other hand, would not necessarily be associated with a history of previous calculus disease of the biliary passages, although that association is frequently present. Pain never occurs as a symptom at the begin- ning of a jaundice due to duct closure from chronic pancreatitis or cancer. In carcinoma of the head of the pancreas there is rarely a history of cholelithiasis, and the loss of flesh and strength may precede development of the jaundice. There is, moreover, as a rule, a gall-bladder tumor due to distension of the viscus with bile. Enlarge- ment of the liver and ascites are generally present late in the disease, the former due to dilatation of the intrahepatic bile ducts, the latter to pressure on the portal vein. The disease occurs late in life. Treatment. — Treatment offers no hope for a radical cure in carcinoma of the pancreas, except in those rare instances of early primary disease limited to a small area in the body or tail of the organ. Finney has reported six resection in such cases, with two operative deaths, and no late observations. Cholecystostomy or cholecystenterostomy may relieve for a time the intense itching and cholemia, but any operation in the later stages of the disease is associated with a high mortality. In the writer's opinion it is justified only when there is a possibility of the symptoms being due to a chronic interstitial pancreatitis. Sarcoma. — This disease is rarely encountered. Hale White reported one case only in 6708 autopsies. It cannot be diagnosticated before operation, as in the case of carcinoma. Operation is indicated only in small circumscribed primary growths in the body or tail. These occasionally may be discovered as a result of an exploratory operation. Four or five such cases are on record. The operative mortality being about 50 per cent. Cysts. — Cysts of the pancreas may be divided into two classes, the true cysts and pseudo cysts, the former arising from some pathologic condition in the gland, the latter, generally traumatic in origin, and due to a hemorrhage or leakage of pancreatic fluid into the lesser peritoneal cavity. Of the true cysts, the commonest is the cyst-adenoma, often similar in structure to the cystadenoma of the ovary in that it has a dense fibrous capsule, is generally multilocular, and may present on its inner surface papillomatous growths. It is frequently lined with columnar epithelium, but this may be absent as a result of digestion by the ferments of the contained fluid. The true hemorrhagic cyst a slowly growing cyst, generally traumatic in character, but having its origin in the glandular tissue of the pancreas. Retention cysts due to an intermittent obstruction of the duct. This results in multiple small dilatations of the canal of Wirsung, and was called by Virchow "pancreatic ranula." Hydatid cysts. These are very rare, and cannot be differentiated from the other varieties before operation. TUMORS OF THE PANCREAS 595 Cystic degeneration of the pancreas is a congenital condition, similar to the congenital cystic kidney, and as a rule gives rise to no symptoms. The false cysts as a rule grow more rapidly than the true cysts. Both true and false cysts contain fluid which on chemical examination is found to be alkaline, albuminous, and may show one or all of the pancreatic ferments, although their absence may be noted in rare instances in either variety. The fluid of a pancreatic cyst may be clear and watery, or thick syrup-like in consistency, and almost any color. Generally it is reddish or brown from the admixture of blood. The presence of blood in a cyst does not necessarily indicate its trau- matic origin, for the pancreatic ferments often cause an erosion of a vessel in the cyst wall, resulting in minute or more extensive hemorrhage. Treatment. — Removal of these cysts is generally out of the question on account of their anatomic relations. They should therefore be opened, the contents evacuated, and permanent drainage established by stitching the cyst wall to the abdominal incision. Numerous cases have been cured by this method, although the secretion may continue for many months. A disagreeable feature of the treatment is the occurrence of an obstinate dermatitis around the fistulous opening, due to the corrosive action of the pancreatic fluid. In a certain proportion of the cyst-adenomata complete extirpation is possible, and this is, of course, the ideal method of treatment. Pancreatic Calculus. — A rare condition. Lazarus, in 1904, collected records of 57 cases. The calculi are generally composed of calcium carbonate and phosphate. They are found in the canal of Wirsung and its larger branches, often they are multiple, and frequently facetted. They are easily shown by the .r-rays. They are generally associated with a certain degree of chronic interstitial pancreatitis. Glycosuria is present in about half of the cases. Symptoms. — There may be no symptoms. Generally there is dull pain or colic in epigastric region to left of midline, or rarely over the gall-bladder. Vomiting occurs if the pain is severe. Chills and fever may be present if infection is added. Jaundice occurs if stone is arrested in the ampulla of Vater. In the intervals between attacks, digestive disturbances of the pancreatic type are often present. The Cammidge reaction is frequently present. Treatment. — If the stone is located at the papilla it may be removed by a transduodenal operation. If in the body of the gland, the pan- creas can be exposed by dividing the gastrocolic omentum, the stones located by palpation, the duct incised, the calculi removed by a curet or scope, the duct wound tightly closed with catgut sutures, and the overlying gland tissue loosely united with interrupted sutures. Generous gauze drainage should be inserted to provide for leakage. 59G DISEASES OF THE ABDOMEN SURGICAL DISEASES OF THE SPLEEN. Congenital Anomalies. — Congenital absence of the spleen has been reported in a few instances. Small accessory spleens are not infre- quently encountered near the parent organ. Occasionally they are attached to the spleen by connective-tissue bands, in other cases, they are to be found in the gastrosplenic omentum or other adjacent peritoneal folds. They are of no surgical importance. Ectopic Spleen. — The spleen may be displaced and occupy almost any position in the abdomen. The causes of this condition are obscure. Symptoms. — There may be no symptoms; or the wandering spleen may cause displacement of the stomach and occasion pain and vomit- ing; it may give rise to intestinal obstruction by pressure on the bowel, or by the formation of adhesions may give rise to a kinking of the gut and stenosis. In a case observed by the writer the spleen was situated in the pelvic cavity, and was firmly adherent to the sacrum, rectum, and bladder, producing symptoms referable entirely to the bladder. In this case there was also axial rotation, the internal surface pointing toward the left and the anterior border being down- ward. Rotation of the spleen with twisting of the pedicle, causing strangulation of the vessels, may give rise to acute pain, vomiting, tenderness, peritoneal irritation, and result in gangrene of the organ. Diagnosis. — The diagnosis occasionally is made by the shape of the tumor, by the recognition of its notched anterior border, and by the fact that frequently it can be reduced to its normal position. Treatment. — Splenopexy, or suturing the organ to the diaphragm or posterior abdominal wall, has been recommended. Hose and Carless recommended making a bed for the wandering organ in the retroperitoneal space near its normal habitat, withdrawing it through an incision in the parietal peritoneum, and securing it by sutures. Splenectomy is, however, the operation of choice. Of sixteen cases of splenectomy for this condition cited by Osier, fifteen recovered. Abscess of the Spleen. — Abscess of the spleen is exceedingly rare, and generally is metastatic in origin. It is often associated with some acute infectious disorder, as typhoid fever, smallpox, acute rheumatism, or gonorrhea. The association of malaria with abscess of the spleen has been mentioned by a number of observers. Trauma has been recorded in a few instances, especially when the spleen subsequently became adherent to a loop of damaged intestine. In a fair number of cases the disease seems to result from an infection of a pre-existing hematoma. Symptoms. — The symptoms of splenic abscess arc pain and tender- ness in the left hypochondric region, muscular rigidity, fever, chills, and leukocytosis. As adhesions frequently form between the spleen and the parietal peritoneum of the diaphragm and abdominal wall, symptoms of pleurisy or infection of the abdominal parietes develop. SURGICAL DISEASES OF THE SPLEEN 597 Treatment.— The treatment should be incision and evacuation of the pus. If pointing occurs on the surface of the body the incision should be over the inflamed area. If no such sign exists, laparotomy is indicated with drainage, as in other intra-abdominal abscesses. Tuberculosis of the Spleen. — A number of cases of splenic tubercu- losis have been recorded, in some of which the disease was apparently primary. The spleen in this condition is generally enlarged, and more or less discomfort and pain are present. Bland-Sutton and others have successfully removed the spleen for this disease, with complete restoration to health. Splenomegaly. — The spleen may be enlarged in acute infectious diseases as typhoid fever or malaria; in tuberculosis, syphilis, and rickets; in cirrhosis of the liver, and other forms of portal obstruction; in leukemia, Hodgkin's disease; hemolytic icterus, pernicious anemia; and in that obscure group of pathologic conditions classified as idio- pathic splenomegaly, Banti's disease, or splenic anemia. While the splenic enlargements of acute and chronic infectious diseases, of cirrhosis of the liver and of leukemia and Hodgkin's disease, as a rule are of interest only to the practitioner of internal medicine, those cases of splenomegaly associated with certain pro- gressive anemias due to hemolysis, w r ith hemorrhages and hemolytic icterus, are now regarded as presenting definite surgical indications. The first of these conditions to be treated surgically was Banti's disease, which may be described as an exceedingly chronic disorder presenting three distinct clinical stages. First the stage of gradual splenic hypertrophy without other symptoms (idiopathic spleno- megaly). This stage may last from two to seven years, and during this period the spleen may enlarge to such an extent as to reach the median line and pelvic brim. I Hiring the second stage there occurs a progressive anemia of the chlorotic type, evidenced by a lowered red cell count, lowered percentage of hemoglobin, low color index, leuko- penia w r ith a relative lymphocytosis; also gastric and intestinal hemor- rhages, evidenced by hematemesis and melena. These hemorrhages occur at irregular intervals, and may result in extreme exsanguination. During this stage also, there is noted a definite enlargement of the liver. The third stage is that of progressive hepatic cirrhosis, the enlarged liver gradually shrinking to a small area, and presenting all the characteristic fibrous changes of an alcoholic cirrhosis. Ascites, increased gastro-intestinal hemorrhages, jaundice, and pigmentation are the characteristic symptoms of this stage, and death from loss of blood or progressive asthenia is the inevitable result in untreated cases. Pathology. — The pathology of the condition is by no means definitely determined. The changes in the spleen in the early stage are, hyper- plasia of all the connective-tissue elements of the organ, with pressure atrophy of the Malpighian corpuscles, chronic passive hyperemia, and endothelial proliferation of the sinuses. In the Gaucher type, this 598 DISEASES OF THE ABDOMEN endothelial proliferation may be so great as to cause huge masses throughout the organ, suggesting a neoplasm. In addition to these changes in the spleen there is always a chronic phlebitis of the splenic vein, often with great thickening and calcification of the walls; and a varicose dilatation of its tributaries especially the vasa brevia from the stomach. The venous changes have been regarded by some to be the primary lesion, the splenic changes resulting from the chronic passive hyperemia. Symptoms. — The clinical course of the Gaucher type differs some- what from the type described by Banti. It occurs more often in child- hood and appears frequently in several members of a family. The splenic enlargement generally is discovered by accident as there are no symptoms until very late in the disease, when anemia develops with hemorrhages from the nose and gums, pigmentation of the skin of the face, neck and hands, and lastly enlargement of the liver. Treatment. — In the treatment of this condition, early splenectomy is to be recommended, as by this means alone can the progress of the disease be arrested. Hemolytic Icterus. — There are two types of this disease, the con- genital and acquired. In the congenital type there may be only a slight jaundice from birth, without anemia or splenic enlargement; or the jaundice may be more marked with moderate splenic hyper- trophy and anemia. The urine contains no bile, but urobilin is present. The stools are normal in color. There is as a rule a certain amount of variation in the jaundice. These cases run a chronic course, and often the health is not impaired. In the acquired type the condition is more acute, while the symptoms and signs are the same in character; the anemia is more pronounced, the splenic enlargement more marked, and enlargement of the liver may be noted. In a few instances in which the spleen has been removed for this condition the results have been brilliant. The jaundice has disappeared or been markedly improved, the urobilin has disappeared from the urine showing a greatly diminished destruction of red cells, and the anemia and general health have been improved. Pernicious Anemia. — As many cases of pernicious anemia seem closely related to hemolytic icterus, Antonelli and Decatello removed the spleen in two borderline cases with excellent results. Later Eppinger reported two cases of hemolytic icterus and two cases of pernicious anemia successfully treated by splenectomy. In neither of the latter cases was the spleen enlarged. Klemperer and Hirschfeld reported two additional cases of pernicious anemia treated in the same manner with marked improvement. Splenectomy apparently acts in two ways in these cases, first by removing the chief seat of the destruction of the red cells, and second by stimulating the bone marrow. Polycythemia has been noted in a number of cases where the spleen has been removed for trauma or Banti 's disease. In one case of the latter disease Klemperer and Hirschfeld report an TUMORS OF THE SPLEEN 599 increase of red cells within a year to over 7,000, 01)0 and of hemoglobin to 120 per cent. In pernicious anemia, so treated, while the blood picture shows much improvement by the marked increase in erythrocytes and normo- blasts, it does not necessarily lose the characteristics typical of the disease. Hypertrophic cirrhosis has recently been treated successfully by splenectomy, notably a case reported by Eppinger operated upon by Brauer. TUMORS OF THE SPLEEN. Primary sarcoma, fibroma, and cavernous angioma have been observed in the spleen. Secondary carcinoma and sarcoma are more common. The benign solid tumors of the spleen are exceedingly rare, and practically never give rise to symptoms calling for surgical intervention . Sarcoma, according to Moynihan, may arise from the capsule or trabecular when it is of the fibrous or spindle-cell type; from the lymphoid tissue, lymphosarcoma; or from the endothelium, endothe- lioma. In the first form the growth is slow, in the others rapid. About one dozen such cases have been treated by splenectomy with two or three permanent recoveries. Cysts of the Spleen. — Those are divided into two classes, the para- sitic and non-parasitic cysts. Echinococcus cysts of the spleen are the ones most frequently observed. The cysts are always unilocular, and according to Moynihan may arise from any part of the organ, but are generally located in the upper pole. The non-parasitic cysts, according to Powers, are generally due to trauma giving rise to paren- chymatous or subcapsular hematoma. These cysts may contain blood, or the fluid may be serous in character. They may reach a large size and occasion symptoms of more or less importance. Gen- erally there is a sense of weight or dragging in the left hypochondriac region. Occasionally there is acute pain or vomiting from pressure on the stomach or intestines. The signs are those of a globular elastic tumor in the upper left quadrant of the abdomen. The most approved and successful treatment is by splenectomy, although cures by drainage and marsupialization have been reported. Splenectomy in the non-parasitic cysts may be rendered difficult by the presence of adhesions. CHAPTER XXII. DISEASES AND INJURIES OF THE KIDNEYS AND URETERS. CONGENITAL ABNORMALITIES OF THE KIDNEY. Congenital abnormalities of the kidney which are of surgical importance are, variations in position, number, and form. The position of the kidney may be anywhere from its normal habitat in the upper loin to the floor of the pelvis. Kidneys occupying a position in the iliac fossa or pelvis are extremely rare, may be misformed, and are not infrequently mistaken for pelvic growths. While the presence of small supernumerary kidneys are of little or no surgical importance, the occurrence of a single kidney only, in an individual who is the victim of a surgical disease of that organ is of the greatest moment. The occurrence of a single large kidney in its normal position, with absence or complete atrophy of its fellow, may be expected once in every 2500 individuals, the actual number reported by Morris in 15,904 autopsies being 6. The occurrence of a single renal mass formed by a fusion of both kidneys is more common, occuring about once in 1000 subjects. When this is present, the mass usually occupies a position in front of the spine near the bifurcation of the aorta, and is of horse-shoe shape. Very rarely the fused mass may be found in the loin on the right or left side of the vertebral column. The fused kidneys may be united by a bridge of kidney parenchyma, or only by a thin fibrous band. Usually they have two sets of vessels and two ureters. The presence of a double renal pelvis and ureter in a kidney otherwise normal is of comparatively frequent occurrence, and may be of surgical importance, especially in interpreting the results of cystoscopic exami- nation. The writer found this condition 3 times in an examination of 150 subjects in the dissecting-room of the College of Physicians and Surgeons of New York. Fig. 288 represents such a condition where the upper pelvis and ureter were the seat of a tuberculous process, while the lower remained free. Variations in the blood supply of the kidney are frequent. The author found in an examination of 150 subjects a double renal artery 70 times; three arteries, 12 times; four, twice; and five, once. Of the latter, three branches came from the aorta, one from the common iliac, and one from the ovarian. Important arterial branches to the CONGENITAL ABNORMALITIES OF THE KIDNEY 60] upper and lower pole of the kidney and to the anterior surface of the organ were found 28 times (Fig. 289). These vascular bands passing to the lower pole of a kidney not infrequently give rise to intermittent Fig. 288. — Double renal pelvis and ureter. Tuberculosis of upper pelvis and ureter. 602 DISEASES OF THE KIDNEYS AND URETERS hydronephrosis by pressure on the ureter, when the organ is fixed, or by kinking of the ureter, when the kidney becomes movable. Fig. 289. — Anomalies of renal artery. INJURIES OF THE KIDNEY. Although one of the best protected organs of the body, the kidney is not infrequently injured by falls, blows, crushes, severe muscular strain, gunshot and stab wounds. These injuries are naturally divided into two classes, those which occur without an external parietal wound leading to the injured organ, and those accompanied by such a wound. The former are spoken of as svbparietal injuries, the latter as open wounds. Like simple fractures, the subparietal injuries generally escape infection from without; and although the injuries are often serious and require grave surgical procedures for their relief, a complicating infection generally can be avoided; while in the open injuries, infection has generally taken place before the patient is seen by the surgeon. The possibility of injury to the kidney by severe muscular effort must be admitted, for cases have been recorded in which lumbar pain, collapse, and hematuria have followed a sudden violent muscular strain, but by far the largest number of such injuries are caused by crushes, falls, or blows in the lumbar region. Subparietal Injuries. — Subparietal injuries of the kidney may be conveniently divided into three grades: (1) simple contusion with or without injury to the capsule and subcapsular hemorrhage; (2) incom- INJURIES OF THE KIDNEY 003 plete rupture, in which the parenchyma is fractured, but without opening the pelvis; and (3) complete rupture, in which the entire organ is torn across, freely opening the pelvic cavity. In simple contusion there is often a laceration of the fatty capsule with a very moderate amount of hemorrhage. One or more fissures of the fibrous capsule may occur with ecchymoses, and occasionally a large area of the fibrous capsule is raised by the presence of extrav- asated blood. In ruptures of the parenchyma the line of fissure generally corresponds with the direction of the bloodvessels. When limited to the cortex, the hemorrhage is moderate; but when complete rupture occurs and the large vessels are torn, the hemorrhage is pro- fuse, often forming an enormous retroperitoneal hematoma or intra- peritoneal extravasation if that membrane is lacerated by the original injury or ruptured by the pressure of the extra vasated blood. When the pelvis or ureter is injured, urinary extravasation necessarily occurs, giving rise to a constantly increasing tumor in the flank, and not infrequently furnishing a source of infection. It occasionally happens that, as a result of a trauma, the kidney escapes damage, the only injury being rupture of one of the vessels of the pedicle, generally a vein. Symptoms. — These vary with the extent of the injury. In simple contusion there may be only the history of a blow or fall, a slight soreness about the loin, and the passage of urine tinged w r ith blood. In severe cases the pain is more marked, and may be of paroxysmal character, radiating downward along the course of the ureter and into the testicle, this presumably due to the passage of blood clots along the ureter. If there has been a considerable extravasation of blood in the perirenal tissues, a tumor may be felt, and possibly fluctuation. The hematoma may be marked and persist for many days; occasionally the blood collects in the bladder so rapidly that an enormous clot is formed distending that organ and giving rise to retention. There is moderate shock, evidenced by pallor, a rapid, feeble pulse, cold extrem- ities, and occasionally nausea and vomiting. Later, suppuration may occur, forming a more or less extensive retroperitoneal abscess, the symptoms of which are general malaise, local throbbing pain, fever, chills, wasting, and the presence of a tender mass in the flank. In the severest forms shock is the prominent symptom. This is due to hemorrhage either extraperitoneal or intraperitoneal, and not infre- quently to injury to other organs caused by the same trauma. The presence of a tumor in the loin or marked local tenderness with hema- turia furnishes the surgeon with sufficient data on which to base a diagnosis, although the patient may be unable to describe the accident or his sensations. These cases are often rapidly fatal from shock due to hemorrhage or the effects of concurrent injuries. A group of persistent symptoms has been described as occasionally following the mildest contusions, which merit special attention. These are paroxysmal pain, fever, hematuria, and frequent micturition, occurring weeks or months after such an injury, and strongly suggesting 004 DISEASES OF THE KIDNEYS AND URETERS the presence of renal calculus. Exploration reveals in these cases extensive subcapsular hematomata, but nothing else. The symptoms are completely relieved by removal of the lesion. In such a case observed by the writer at the Roosevelt Hospital an .r-ray photograph showed a faint shadow in the region of the blood clot, which still further obscured the diagnosis. Prognosis. — As in the case of all visceral injuries, the prognosis should he guarded. The mild cases recover almost without exception, and even the cases with extensive hematomata result favorably if infection is avoided. Where urinary infiltration complicates the injury, the prognosis is more grave, and where these and the severer forms of injury cannot receive prompt surgical assistance the outlook is bad. It is a well-recognized fact that injury to an organ, particularly the kidney, will so affect its nutrition as to diminish its normal resist- ance to septic infection. The frequent occurrence of septic infarcts or an ascending infection in a previously injured kidney has been noted by all clinical observers. Treatment. — Except in the mildest contusions, all cases of injury to the kidney immediately should be explored, for the reason that the early symptoms often give no adequate idea of the extent of the injury. Unless there are evidences of intraperitoneal injury the exploration should be by the lumbar route. This exposure of the kidney and retroperitoneal space will enable the surgeon to estimate correctly the extent of the injury, arrest the hemorrhage, remove the clot and extravasated urine, and provide adequate drainage. The treatment of the injured organ must be determined by the extent of the trauma. If the kidney is simply torn apart, often it may be saved by careful approximation of the divided portion even if the cavity of the pelvis is invaded, for the great vascularity of the organ favors rapid repair. The placing of a few catgut sutures through the capsule, or even through the kidney itself, will be sufficient to insure continued approx- imation until repair has taken place. Whenever the pelvis is opened and hemorrhage is free, it is wise before closing the rent to insure patency of the ureter by the passage of an ureteral catheter to the bladder. Whenever urinary extravasation has occurred, the wound should be left partly open and generously drained with gauze or rubber tubes. In the severe forms, in which the kidney is not only torn, but also crushed and large areas of the parenchyma destroyed, and in cases in which the blood supply has been seriously compromised or in which the pelvis or ureter has been injured beyond repair, nephrectomy should be practised. Nephrectomy is occasionally advisable also in cases of severe shock accompanied by grave hemorrhage, in which prolonged attempts at repair would not be tolerated. Prompt healing may be expected in those cases which recover INJURIES OF THE KIDNEY G05 from the immediate shock of the injury and operation, if infection can be prevented. Where infection occurs, however, the suppurating area is apt to be large and the resulting toxemia great, seriously interfering with repair, and often exhausting the patient's vital forces before recovery can take place. In these cases secondary nephrectomy is often necessary to save life, and should not be too long delayed. Open Wounds. — Open wounds of the kidney in the great majority of cases are gunshot or stab injuries, although crushes may result in compound fractures of the lower ribs, and severe railway accidents, machinery injuries, and the flying debris from explosions may cause them. Abbe has reported a case in which the pole of a truck pene- trated the thorax, lacerating the lung, liver, and kidney. In these instances, in addition to the other dangers we have the added risk of infection, as bits of clothing and other infected matters are practically always present in the wound, a circumstance which should lead the surgeon to an immediate exploration in every instance in which the patient's condition justifies the administration of an anesthetic. After the wounded area is freely exposed and disinfected the same principles should be carried out in the treatment of the injured organ as in cases of subparietal injury. In gunshot and stab injuries when the direction of the wound leads one to infer that the peritoneal cavity may be injured, it is advisable to perform an immediate exploratory laparotomy, even in the absence of symptoms of intra-abdominal lesion. Aneurism of the Renal Artery. — True spontaneous aneurism of the renal artery is exceedingly rare. True or false aneurism arising as a result of trauma is of more frequent occurrence, but is seldom recognized. True traumatic aneurism, or one in which the walls are formed by one or more coats of the artery, rarely reaches a large size without rupture. When such an aneurism ruptures, or when as a result of injury a healthy arterial trunk is ruptured, a false aneurism may result, the walls which may be formed by the fibrous capsule of the kidney, the distended pelvic cavity, the parenchyma of the organ, or the sur- rounding areolar tissue. This aneurism may enlarge slowly or rapidly, and eventually may form a tumor large enough to fill half the abdominal cavity. These aneurisms are of interest to the surgeon for the reason that they constitute one of the later complications of a kidney trauma, and also for the reason that they are often extremely difficult to diagnosticate, owing to the frequent absence of the classic signs of aneurism, pulsation, thrill, and bruit. They are important for the reason that they tend to an invariable fatal termination unless relieved by surgical operation. Symptoms. — The chief symptoms are tumor and hematuria. The tumor may develop rapidly 01 slowly according to the size of the ruptured vessel or the resistance of the surrounding tissue. It is 606 DISEASES OF THE KIDNEYS AND URETERS not, as a rule, movable, and is rarely tender. Hematuria is present in the majority of cases, and may be continuous or intermittent. The persistence of hematuria after an injury and the occurrence of a progressively increasing tumor in the flank without other symptoms should suggest the possibility of false aneurism. Treatment. — The treatment should be nephrectomy and complete removal of the sac. This in large tumors is accompanied by grave danger of hemorrhage and shock. It should be accomplished through a large incision or by the combined lumbar and abdominal route, the advantage of the abdominal opening being to secure more easily the vessels of the pedicle. Movable Kidney. — Slight vertical mobility of the kidney is present normally, but this cannot, as a rule, be appreciated by palpation except in cases of marked emaciation or abnormal laxity of the abnormal wall. The kidney is held in position by its vascular connections with the aorta and vena cava; by the so-called perinephric fascia, which is simply a separation into two layers of the posterior portion of the transversalis or deep fascia of the abdomen, which invests the kidney and its fatty envelope in a kind of secondary capsule; by the perirenal fat; by its anterior peritoneal adhesions, and by pressure of other abdominal organs. The causes which are mostly responsible for abnormal mobility of this organ are: wasting diseases, causing absorption of the perirenal fat; frequent pregnancies, the removal of large tumors or collections or ascitic fluids, causing laxity of the abdominal walls; ptosis of other organs; congenital or acquired relaxation of the peritoneal and fascial connections, and, rarely, trauma. In the majority of instances movable kidney occurs in tall, long-waisted, thin women. Becker and Lenhoff observed this so frequently that they were able to predict, from the general appearance and certain measurements of a patient, whether or not the kidney could be palpated. 1 M. L. Harris believes that in this type of individual, contraction of the space immediately below the diaphragm, by straining, coughing, or body movements, causes pressure upon the upper pole of the kidney, and thus forces it downward. The frequency of movable kidney is variously estimated to be from 4 to 40 per cent, of all individuals. Eight-tenths of the cases occur in women. The writer found it present to a pathologic degree in 11 of a series of 200 living subjects examined without reference to symptoms, and in 14 of 150 subjects examined in the dissecting-room of the College of Physicians and Surgeons the kidney was found to be freely movable or out of its normal position. The association of movable kidney with general enteroptosis is 1 The index of the body form was obtained by dividing the distance from the supra- sternal notch to the symphysis pubis, by the least circumference of the abdomen, and multiplying it by 100. If the result was above 77 the kidney generally could be palpated; if below 75, it could not. INJURIES OF THE KIDNEY 607 occasionally seen, and presents, as a rule, a fairly typical clinical picture; but this association, said by Glenard to be constant, has not been found so frequently by subsequent observers. The method of determining the presence of a movable kidney is to place the patient in the dorsal position on a hard mattress or table. The abdominal muscles should be relaxed by drawing up the legs. One hand of the examiner should be placed in the costo- vertebral angle, the other flatly laid over the rectus muscle near its attachment to the costal cartilages. By gently approximating the two hands and instructing the patient to take a deep inspiration, the kidney if abnormally movable easily can be felt by the hand of the examiner except in cases of great obesity or muscular rigidity. It is convenient to describe three degrees of mobility. A kidney is said to be palpable when the lower pole can be felt by the examiner during deep inspiration; movable, when the entire kidney can be palpated; and floating, when it can be grasped and moved about by the hand or makes extensive excursions to the pelvis or other portions of the abdominal cavity. Symptoms.- — In the majority of instances no symptoms accompany this condition, the discovery of a movable kidney being made by accident or during the course of a systematic abdominal examination. When present the symptoms may be classified as digestive, neuras- thenic and renal. The digestive symptoms may or may not have an organic basis. Traction on the duodenum or kinking, might give rise to pyloric stenosis; and an associated gastroptosis might cause diminished motility; but these are not the symptoms which usually accompany movable kidney. The digestive symptoms ordinarily present have generally a strong neurasthenic flavor. Vague pains before or after meals, in the epigastrium or substernal region, right or left iliac fossa, over the ovary, appendix or gall-bladder, occurring at no regular time and changing in character and position each day. Areas of marked abdominal tenderness to even the gentlest pressure, these also changing their position daily and with each medical examination; a prominent aorta with exaggerated pulsation, pelvic pain, constipation, menstrual disturbances, nausea, gas, cribbing, parasthesias, and emo- tional instability. Of the definite renal symptoms which may be caused by movable kidney, that group known as Dietls' crisis is the most char- acteristic. It is caused by a transitory hydronephrosis due to ureteral obstruction from kinking, the result of a marked descent of the organ or forward rotation. Acute renal hyperemia might easily be produced by a similar twisting of the vascular pedicle, and may be an element in the symptom complex. Pain, sudden and severe, occurring in the epigastrium or lumbar region, radiating downward along the course of the ureter to the testicle or penis. Nausea, vomiting, weakness, collapse, and the presence of a tender renal tumor, which suddenly disappears with active diuresis and complete relief of pain. These attacks occur at irregular intervals, and occasion great suffering. 608 DISEASES OF THE KIDNEYS AND URETERS The duration of symptoms is exceedingly variable. Another definite symptom of movable kidney may be a more or less constant dragging pain over the gall-bladder or liver from traction on the peritoneal folds connecting these organs. Prognosis. — Relief to the purely local renal symptoms may be looked for if the condition can be corrected by apparatus or operation. If the symptoms, however, are largely those of neurasthenia, malnutri- tion, or indefinite disorders of digestion, with vague pains in the abdomen or pelvis, the prognosis should be guarded. The writer has observed that in a large proportion of the neurotic cases, operation has proved of no value, and in not a few the condition has been aggravated by the addition of a traumatic neurasthenia. Treatment. — In cases in which the mobility of the kidney is appar- ently due to absorption of the perirenal fat, the rest-cure, with a generous diet made up largely of the carbohydrates, will often be of value. If this method is followed, absolute rest in bed must be insisted upon for at least six weeks. The use of pads and abdominal binders may be tried, but there is little reason to suppose that they accomplish much in these cases. The best method is to apply even compression over the entire abdomen by means of an elastic, tightly fitting corset, as advised by Israel. Gallant obtains satisfactory results by the use of the modern straight front corset applied in the morning before leaving bed. The corset should be two sizes smaller than usual, and should be snugly applied with the patient on the back, the hips being elevated. In the great majority of cases, however, nephrorrhaphy is the method of choice, and should be advised in all instances where the lesion results in a definite Dietl's crisis, or where the painful local symptoms can be rationally attributed to peritoneal traction or hyperemia of the organ. INFLAMMATORY DISEASES OF THE KIDNEY. Renal Suppuration. — Renal suppuration may arise from infection conveyed to the organ directly by a penetrating wound, by extension from a neighboring focus, by an ascending process from the lower urinary passages, or by the blood current. The first two methods are exceedingly rare; the last two of frequent occurrence. Considerable difference of opinion in the past has existed among surgeons regarding the comparative frequency of ascending and blood infections of the kidney, and while all agree that ascending affections are of fairly frequent occurrence, the majority of the grave suppurating lesions of the organ are now generally admitted to be of hematogenous origin. As both methods of infection may give rise to practically the same clinical types of diseases, a brief description of each may be in order before taking up the individual diseases. Ascending Infections. — Ascending infections are favored by any interference with the normal outflow of urine from the bladder; they INFLAMMATORY DISEASES OF THE KIDNEY 609 arc also favored by any factor which results in forcing the ureteric sphincter, allowing a reflux of contaminated urine in the ureter; or in a diminished resistance on the part of the individual. Albarran has shown that cultures of the most virulent micro-organisms may, with impunity, be injected into the bladders of dogs as long as there is no obstruction to the normal outflow of urine, but that a fatal pyelo- nephritis results if an artificial retention is produced by ligation of the urethra. It is likewise well known that in the aged and in those whose resistance has been greatly diminished by dissipation and disease, involvement of the kidneys is far more frequent from the extension upward of an infection of the bladder or urethra than in young subjects and those who enjoy robust health. Given, therefore, a .case of acute or chronic retention of urine from stricture, prostatic abscess or senile enlargement; and add to this, infection, from the extension backwards of a gonorrhea, or, introduced by the passage of an unclean instrument, and we have the conditions favoring an ascending infection. The first result is an active cystitis, which is soon followed by an extension of the inflammation to the renal pelvis, where it rapidly ascends the straight tubules, and results in multiple foci of infection in the cortex and acute degeneration of the epithelium of the tubules and glomeruli. This not infrequently causes a complete suspension of the renal function, with death from a com- bination of uremia and sepsis. In certain instances the ureteral mucous membrane apparently takes no part in the process, the infection reaching the kidney by means of the periureteral lymphatics. The presence of a ureteral calculus or new growth, of a tuberculous area of the trigone, or any other factor which causes severe vesical tenesmus and interferes with the normal sphincteric action of the lower end of one ureter, will act as a predisposing cause of unilateral renal infection. In the milder types of ascending infection the process may be arrested at any point. The terminal condition, therefore, may be pyelitis, pyelonephritis, pyonephrosis, cortical abscess, or perinephritis. Hematogenous Infections. — Hematogenous infections of the kidney are produced by pathogenic micro-organisms conveyed to the organ by the blood current. It is a well-known and generally accepted fact that during the progress of any acute infectious or septic disease, certain micro-organisms, giving rise to the symptoms, find their way into the blood current, and are either destroyed by the bactericidal action of the blood itself, or by substances encountered in the passage of the blood through certain organs, or they are excreted through the kidneys. Pernice and Scagliosi, in Virchow's Archiv, 1894, give the results of an elaborate series of experiments, showing the anatomic changes occurring in the kidney by the excretion of various pathogenic and non-pathogenic bacteria. Albarran, in 1889, reviewed the entire subject of renal infection, and concluded that pathogenic bacteria may, under certain conditions, 39 610 DISEASES OF THE KIDNEYS AND URETERS be eliminated through the kidneys without producing marked anatomic lesions; their elimination, on the other hand, may give rise to a bac- terium, to a glomerular nephritis with degeneration of the epithelium, to multiple non-pyogenic infarcts, to pyogenic infarcts or multiple abscesses, to perinephritic abscess, to pyelonephritis, or to a rapidly fatal toxemia. Pie also stated that the effects of trauma, excessive functional activity, the presence of toxic products, and renal retention, all served to accentuate the process and to favor the formation of graver lesions. The lesions most commonly found in these cases are due to a plugging of the smaller arteries and capillary vessels with groups of organisms. These minute emboli are later surrounded by a zone of round-cell infiltration. Where the larger trunks are thus involved, triangular infarcts are produced; where the capillaries only are involved, minute abscesses are seen throughout the cortex and beneath the capsule. If the process progresses, the bacterial emboli are rarely recognized; only areas of necrosis or purulent infiltration are apparent. At a still later stage many of these collections of pus coalesce, forming larger parenchymatous abscesses, which may rupture through the capsule, giving rise to perinephritis, or into the pelvis, giving the typical picture of pyelonephritis. It will thus be seen that both the ascending and the blood infections may give rise to lesions which, on gross inspection, appear identical, and each may result in three degrees or types of infection: the acute or fulminating, often rapidly fatal; the subacute, progressing slower and resulting in the classical types of renal suppuration as pyelitis, pyelonephritis, pyonephrosis, perinephritis, etc.; and an exceedingly mild type which often recovers spontaneously and presents no surgical indications. Acute Ascending Infection of the Kidney. — The commonest type of this variety of renal infection is seen in the aged victims of chronic urinary obstruction from old urethral stricture or prostatic hyper- trophy. In these cases the bladder often is enormously dilated with both ureteral sphincters open, or easily forced by severe straining or tenesmus. Into this bladder, infection may be introduced by the first passage of a catheter, often for purposes of diagnosis. When this occurs, death frequently results within ten days, from acute bilateral pyelonephritis. Diagnosis. — In these cases the symptoms are characteristic, but often fail to impress a careless medical observer as being due to renal infec- tion on account of the absence of lumbar pain. The first relief from the bladder distension is followed by a short period of freedom from all symptoms, then follows a chill with rapidly rising temperature, headache, anorexia, great weakness and a diminished secretion of urine. Later the urine appears smoky and finally suppression occurs with delirium, coma, and death. In these rapidly fatal cases both kidneys are involved in the process. In a few instances PLATE XXI Acute Hematogenous Infection of Kidney. Organ bisected, showing anterior and posterior surfaces. (Lumiere Photograph.) INFLAMMATORY DISEASES OF THE KIDNEY (ill the infection seems either limited to one kidney or the second kidney is but slightly involved. In these cases the symptoms are those of a rapidly advancing sepsis without suppression of urine; and if the process continues sufficiently long, signs of a unilateral septic kidney may result, as localized pain, tenderness and possibly the presence of a sensitive renal tremor. Cystoscopy and ureteral catheterization may aid greatly in the diagnosis and in furnishing indications for treatment. Prognosis. — Except in the rare unilateral cases, the prognosis in this acute fulminating type is exceedingly grave. In the unilateral cases life sometimes may be saved by a timely operation. Treatment. — In the bilateral cases, the indications are to drain the bladder, and to administer diuretics and urotropin. Proctoclysis by the Murphy drip method, and intravenous saline infusions are of value, and the question of double renal decapsulation may be considered. In the unilateral type nephrotomy with drainage or nephrectomy may be employed in suitable cases. Acute Unilateral Hematogenous Infection of the Kidney. — While most surgeons of experience appreciate the relationship between hematogenous infection and the easily recognized advanced types of renal suppuration, three important facts regarding the behavior of this variety of infection are not generally appreciated by the pro- fession. The first is that the lesions are often unilateral; the second, that in the severest type of the affection the toxemia is so overwhelming that death often occurs before any characteristic renal symptoms are developed; and the third is that these cases, in their early sympto- matology, vary greatly, the clinical picture often suggesting an acute grip, lobar pneumonia, appendicitis, or cholecystitis. These facts would warrant a separate consideration of the acute fulminating type, which, by its symptom complex, deserves recognition as a distinct pathologic entity. Two factors are necessary for the production of this type of renal lesion: (1) A septic focus somewhere in the body capable of furnishing a certain number of pathogenic bacteria to the blood current; and (2) a diminished resistance on the part of one kidney due to trauma, the presence of a calculus, an obstructed ureter, or a previous septic lesion. The disease, therefore, not infrequently follows pneumonia, tonsillitis, any of the exanthemata, typhoid fever, a furuncle, or possibly obstinate constipation, as the colon bacillus often is the offending organism. Over SO per cent, of the cases are observed in women, and in a large majority of instances the right kidney is the one affected. In the severest cases the perirenal fat and areolar tissue are edema- tous, the kidney moderately enlarged and deeply congested. The surface is studded with deep red, elevated areas or groups of miliary abscesses. Plate XXI. On section one or more triangular infarcts may be seen with numerous necrotic areas and suppurative foci. There is marked cloudy swelling of the cortex (Fig. 290). 612 DISEASES OF THE KIDNEYS AND URETERS The organisms most frequently obtained by culture from these lesions are the colon bacillus, bacillus typhosus, streptococcus pyogenes, and staphylococcus aureus. The author has been able to reproduce these lesions in animals by all of the above-mentioned organisms, and also by the pneumococcus and bacillus pyocyaneus. Diagnosis. — The disease may or may not be ushered in by a chill. When present it generally indicates a severe type of infection. The initial rise of temperature is high, generally 104° or 105° F.; the pulse is frequently 120 or more. The toxemia is marked from the first and, Fig. 290. — Acute septic infarcts of kidney. (Blake. ) with the high fever, suggests often an acute grip, lobar pneumonia or one of the exanthemata. Then follows a more or less vague pain in the abdomen or flank corresponding to the side of the lesion. Ten- derness and muscular rigidity over the region of the appendix or gall- bladder leads often to error in believing one of these organs to be the seat of disease. As the urinary secretion from the infected kidney is greatly diminished and is largely diluted by the abundant secretion from the unaffected organ, the mixed urine, when passed or drawn from the bladder, is often quite normal in appearance, and the slight trace of albumin, blood, and pus is often overlooked unless a more than INFLAMMATORY DISEASES OF THE KIDNEY 613 ordinarily careful examination is made. The one pathognomonic sign present in all cases is a marked unilateral costovertebral tenderness. Prognosis. — In regard to prognosis it may be stated that in the severe cases death almost invariably occurs unless the symptoms are promptly arrested by nephrectomy. Many of the less severe cases, if untreated, go on to the development of the gross suppurative lesions to be considered in the next section, while many of the mildest type recover spontaneously. Treatment. — In regard to treatment, the cases should be divided into three classes : The severe type, in which the temperature remains high and the toxemia is rapidly progressive. These cases require nephrectomy at the earliest possible moment. The milder eases are those in which the initial temperature may be high, but begins to fall within forty- eight hours, and where the toxemia is less marked. These cases often may be successfully treated by decapsulation, which relieves the intense congestion and allows nature to complete the reparative process. Where one or more cortical abscesses are present, they should be opened and drained. In the mildest type the case may be treated expectantly with a reasonable prospect of complete recovery, although the writer has observed two or three patients in which a chronic nephritis or pyelonephritis has remained. Pyelitis. — Pyelitis is an inflammation of the pelvis of the kidney and ureter, caused by infection from the rupture of a septic focus in the kidney-substance, or from an extension upward of infection from the bladder and lower urinary passages. The author never has been convinced that suppurative pyelitis ever arises spontaneously, or that a blood infection of the renal pelvis ever occurs without lesions in the kidney substance. In the majority of cases pyelitis is accompanied b}' nephritis, and to this condition the term yyeloneyhritis should be applied. Morris has described a form of non-suppurative pyelonephritis, in which the lesion of the renal parenchyma consists in an acute toxic but non- suppurative interstitial inflammation. This is present in a fair proportion of the cases of pyelitis, and may seriously compromise the renal function. By far the greater number of these cases arise from infection from below, due to contamination of the bladder through the introduction of instruments or to extension upward of a gonorrheal urethritis. In these instances the disease is frequently bilateral. Conditions which favor kidney infection in this manner are: back pressure of urine from obstructive disease of the prostate or urethra, mobility of the kidney, and the presence of calculus. Symptoms. — In uncomplicated pyelitis the symptoms are: fever, lumbar pain, vesical irritability, and occasionally, a diminished secre- tion of urine containing albumin, casts, pus, and blood. Suppression of urine, delirium, and stupor may follow if the kidney parenchyma 614 DISEASES OF THE KIDNEYS AND URETERS is extensively involved, and the attack ends fatally in a few days. In the milder cases the patient may live through the acute stage and pass into one of chronic pyelonephritis, in which the only evidence of disease may be the presence of albumin and pus in the urine. This condition may be present for years, the patients apparently enjoying fair health, but a recurrence of the acute symptoms may be expected to follow renewed irritation of the lower urinary passages, the abuse of alcohol, or the administration of an anesthetic. In the milder cases, especially if of gonorrheal origin, complete recovery may take place. Treatment. — The treatment should consist of rest in bed, diuretics, and the internal administration of urotropin in doses of from 5 to 15 grains two or three times a day, taken in large quantities of water. The symptoms of uremia must be controlled by free catharsis and diaphoresis, those of sepsis by heart tonics and supporting measures. The use of prolonged rectal irrigation with normal salt solution, or intravenous infusions of the same agent, are often followed by the most satisfactory results, both on the circulation and the function of the kidneys. Suppurative Pyelonephritis. — In this disease the infection is a pyogenic one, and results in the formation of multiple foci of suppura- tion in the parenchyma of the kidney. These may coalesce and form one or more large abscesses, or the entire organ may be honeycombed with suppurating areas. As in the non-suppurative form of the disease, the infection may reach the kidney by an upward extension from the lower urinary passages, or it may be the result of infection conveyed to the organ by the blood from some distant focus. In the former event the disease is generally bilateral, in the latter more often it is unilateral. It occasionally happens, as pointed out by Alexander Johnson, that in many bilateral cases the chief destructive lesion frequently is located in one kidney; and that the impaired functional activity of the other may be largely due to the coexisting toxemia. Symptoms. — The symptoms of this condition are practically the same as in the non-suppurative form of the disease, with the addition of a more marked pyuria, leukocytosis, and the presence often of fever and a tender kidney tumor. Abscess of the Kidney. — Abscess of the kidney-substance may occur independently or in connection with suppurative pyelonephritis. It may be caused by the coalescence of several small foci of suppuration, may arise from a septic embolus, or from the infection of a single blood-clot or mass of damaged tissue due to trauma. As in the former condition, the infection reaches the organ through the blood or from the lower urinary organs. The association of abscess of the kidney and calculus has been frequently noted. One or both kidneys may be involved. One abscess only may be present, or several may occur in the same kidney. As the disease advances the normal tissue of the kidney is destroyed, and if the progress is not arrested this leads to an INFLAMMATORY DISEASES OF THE KIDNEY 615 opening either into the renal pelvis or through the capsule into the perirenal tissues. In the former event the disease may be cured spontaneously, in the latter a perinephritic suppuration results. Symptoms. — The course of the disease may be acute or subacute; in the acute forms the clinical picture is one of acute progressive sepsis accompanied by pain in the affected side and a diminished secretion of urine. The urine may be albuminous, but contains no appreciable quantity of pus unless the abscess ruptures into the pelvis. There is a marked leukocytosis, and hematuria may be present. Examination may reveal the presence of a renal tumor, but this is not common. Tenderness is generally present and often muscular rigidity. If the condition is accompanied by perinephritis, there are edema and induration in the flank, and later fluctuation may be detected. Prognosis. — In the subacute cases the symptoms may be misleading, the condition being diagnosticated typhoid fever or malaria. This mistake, however, should never occur if a blood examination can be made. In the severe cases, if unrelieved by surgical means or by spontaneous rupture, death may be expected from sepsis within two or three weeks. The spontaneous evacuation of the pus into the pelvis, ureter, or intestine, may result in a sudden and complete disappearance of the symptoms, and recovery may follow without further treatment. Pyonephrosis. — -This condition may represent the terminal stage of any acute suppurative process in the kidney. It is generally unilateral and consists in a dilatation of the renal pelvis with pus from plugging of the ureter with a calculus, a bit of fibrin, or clot of blood; or it may result from the infection of a hydronephrosis. In either event the kidney-substance is quickly destroyed both by the pressure of the accumulated fluid and the destructive tendency of the infection. Symptoms. — The symptoms are acute pain and tenderness in the flank, with chills, fever, sweats, and general prostration. The urine may be negative; blood examination reveals a marked increase in the leukocytes. On physical examination a tender tumor generally can be found in the lumbar region, which is oval, elastic, and may move slightly with respiration. It is best appreciated by bimanual palpation, and generally can be demonstrated to lie behind the colon. Treatment of Suppurative Disease of the Kidney. — There is a grow- ing tendency among surgeons to employ more radical measures in the treatment of the suppurative diseases of the kidney. Formerly pyelonephritis was regarded as beyond the reach of surgical relief for the reason that the lesion was supposed always to be bilateral, and the treatment of kidney abscess and pyonephrosis was limited to incision and drainage, postponing to a later period the nephrectomy which generally was found to be necessary. It was held by many that secondary nephrectomy was a far safer operation than immediate removal of the organ. Recent observations, however, have shown that 616 DISEASES OF THE KIDNEYS AND URETERS in the majority of instances better results can be obtained by primary nephrectomy in these hopelessly diseased kidneys than by nephrotomy, which rarely results in a cure, and which always leaves behind a focus of infection which may result in a persistent sinus and prevent complete recovery from the sepsis. Nephrotomy is indicated in conditions of grave sepsis in which prolonged operation would be fatal; but in these cases the secondary nephrectomy should be performed as soon as the condition of the patient permits, as adhesions soon form which often render the secondary nephrectomy an exceedingly difficult and dan- gerous procedure. When nephrotomy is employed, the kidney should be exposed by a lumbar incision, the suppurating cavity opened by an incision through the convex border, the finger introduced, and all septa broken down, allowing free drainage, which should be maintained by the use of a large rubber drainage tube introduced into the suppurating cavity and surrounded by a snug gauze packing to guard against hemorrhage, which is often severe and controlled with difficulty. In all operations upon cases of acute renal sepsis the surgeon should aim to complete his operation in the shortest time compatible with accurate work, as prolonged anesthesia and exposure on the operating- table may seriously interfere with the function of the remaining kidney, perhaps already compromised by the coexisting toxemia. In all such cases it has been the writer's custom to administer an intravenous infusion of from 500 to 1500 cc. of normal salt solution immediately after operation with a view to increasing the activity of the skin and of the remaining kidney. Perinephritic Abscess. — Perinephritis or perinephritic abscess is an inflammation of the retroperitoneal connective tissue surrounding the kidney. This may arise from an infection derived from the kidney or bowel, from the blood, or from the lymphatics; or it may result from the introduction of infectious material from without by means of a penetrating wound. It is commonly, therefore, associated with suppuration or trauma of the kidney, ulcer of the large intestine, appendicitis, inflammatory processes in the pelvis, spine, or extremities; or occurs as a metastatic lesion in general sepsis. The process may be limited to the region of the kidney, or may extend upward behind the liver or downward to the region of the pelvic brim or groin. If unrelieved, rupture may take place into the bowel or externally. In one case of gas bacillus infection under observation of the writer the pus burrowed downward through the inguinal canal and infiltrated the subcutaneous cellular tissue, involving nearly one-half of the abdominal wall, and causing extensive necrosis of the external oblique muscle and its aponeurosis. Symptoms. — The symptoms are at first pain in the kidney region with fever. If the process is an acute one, there may be early chills and rapid development of profound sepsis, with increasing pain and tenderness in the affected side. In the rare cases of infection by the INFLAMMATORY DISEASES OF THE KIDNEY 017 B. Aerogenes Capsulatus which usually result from intestinal ulcera- tion, the process is one of extreme virulence, all the tissues of the abdominal wall becoming quickly involved, as evidenced by a rapidly advancing redness and edema of the skin with subcutaneous gas crepitus. Generally, however, the process is slower, the patient may not feel ill enough to be in bed, and may keep about for a week or longer. In these instances the gait is characteristic, the body is bent forward and toward the affected side, and the thigh is never fully extended in walking. The fever gradually rises, the temperature curve not infrequently being like that of typhoid fever. As the pain increases, chills develop, followed by sweats and prostration. Exami- nation reveals tenderness, muscular rigidity, induration, and edema of the flank. Blood examination reveals a high leukocytosis. The urine may be negative or give evidences of nephritis. The danger in the severe cases is from the early development of a fatal sepsis; in the milder cases, if unrelieved by appropriate surgical measures, from exhaustion and degenerative changes in the other organ. Spontaneous recovery may take place by rupture into the bowel, or possibly in very mild cases by subsidence of the inflammatory process and encapsulation of the small focus of pus. In the rare cases of gas bacillus infection, the outlook is almost hopeless — death from extreme toxemia taking place often within forty-eight hours. Treatment. — The treatment should be early incision, thorough exploration, and adequate drainage. Occasionally a completely disorganized kidney, large masses of necrotic tissue, or broken-down lymph nodes may be present, and should be removed. The best incision for this is the oblique lateral one described on page 639. One or more counter-incisions may be necessary to insure adequate drainage. The toxemia should be combated by generous diet, stimulants, and tonics. Syphilis of the Kidney. — Syphilis of the kidney occurs during the secondary and tertiary stages of the disease. In the early secondary period a temporary albuminuria may be present as in the case of other infectious diseases. This usually yields to mercurial treatment, or it may pass into the form of a chronic interstitial or diffuse nephritis. These chronic forms more often develop during the later stages of the disease, and are not influenced by treatment. The only syphilitic lesion of surgical importance is the gummatous nephritis with or without interstitial changes. This not infrequently gives rise to a distinct enlargement of the organ, strongly suggesting a new growth or tuberculosis. Symptoms of this condition may be entirely wanting, or there may be lumbar pain, hematuria, or vesical irritability. If the gummatous mass softens and ruptures into the pelvis, the urine may give evidences of the disease by the presence of purulent or gummatous matter or bits of necrotic tissue. The condition 618 DISEASES OF THE KIDNEYS AND URETERS is often mistaken for tuberculosis. In doubtful cases the Wassermann reaction and the guinea-pig test may help to establish the diagnosis. Treatment. — The treatment is purely medical unless the disorganiza- tion of the kidney is so advanced as to require nephrectomy, which should be performed whenever it is demonstrated that medical treat- ment fails to arrest the progress of the disease. Tuberculosis of the Kidney. — While tuberculosis may occur in any part of the genito-urinary tract, its earliest manifestations appear, in the majority of instances, to take place in the kidney. Genito- urinary tuberculosis is always secondary, the infection being derived frequently from some obscure and often unrecognized lesion, as a bronchial or mediastinal lymph node. The infection may reach the kidney by the blood current which is common, by means of an ascending process from the bladder, which is rare, or possibly by direct extension through the lymphatics as recently suggested by Brongersma and Hugh Cabot. In the beginning it is unilateral in about 80 per cent, of the cases, and even in autopsy reports, freedom from the disease on one side, is demonstrated in from 30 to 50 per cent. In the hematogenous infections, miliary tubercles appear in the cortex and beneath the capsule. These enlarge and coalesce forming cavities generally located above and between the pyramides which extend and often break into one of the calices or pelvis. These struc- tures in turn become diseased and the process extends downward along the ureter to the bladder. Occasionally lesions occur in the bladder before gross changes can be detected in the ureter. In the ascending type, which according to the observations of Kapsammer occurs but once to sixty-two cases of blood infection, the disease gradually extends upward along the ureter until the pelvis is reached. This becomes thickened and ulcerated, the pathological changes being most marked at the upper and lower pole. From here the process appears to extend upward along the straight tubules, eventually reaching the cortex, where it may produce cortical areas of softening or abscesses in every way similar to those which result from a blood infection. The old view that tuberculosis of the kidney after extending down- ward to the bladder with the current of urine, could then extend through the prostate or seminal vesicles along the van deferens against the seminal current to the epididymis and testicle, or that a process arising in the epididymis could eventually reach the kidney by ascend- ing the ureter along the mucous membrane against the urinary current, is now generally abandoned. In those rare cases in which the disease does ascend the ureter, it is probably due to lymphatic extension, rather than an ascending process along the mucous membrane. In the ureter as in the bladder, the lymphatics are largely situated on the outer side of the fibrous tunic, few only being found in the mucous membrane or submucous tissue. The ascending lymphatic infections, INFLAMMATORY DISEASES OF THE KIDNEY 619 therefore, rarely occur except in those late cases where the process has involved the deeper structures of the bladder wall. When, there- fore, the second kidney or a testicle becomes involved secondary to an initial renal focus, it is probable that the infection is hematogenous in origin. The fibrous capsule of the kidney acts as an effective barrier to the extension of the disease, and one rarely observes a tuberculous infection of the perirenal fatty tissues, although great thickening of these tissues may occur in cases of mixed infection. Ureteral obstruction from an impacted stone, a blood clot, bit of necrotic or caseous tissue or from closure of the lumen from edema or inflammatory thickening of the ureteral wall, causes pyonephrosis with dilatation of the pelvic and pressure atrophy of the renal paren- chyma. The course of the disease varies greatly. In some instances of acute miliary tuberculosis with extensive involvement of the organs, the progress is very rapid and death may occur in a few weeks or months after the first renal symptom has been noted. In the majority of cases, however, the progress of the disease is slow, often without definite symptoms, or with long periods of remission; and in not a few instances, under favorable hygienic conditions, the disease seems to be permanently arrested. In those cases it is probable that the entire kidney has been destroyed, the fibrous capsule thickened, and the caseating mass completely isolated and often calcified. Symptoms. — Tuberculous infection of the kidney may exist for years without giving rise to any characteristic renal symptoms, and with little or no impairment of the general health. Frequency of micturition and polyuria are generally the first signs, the urine remain- ing clear and without chemical change, other than a lowered specific gravity. Later the urine becomes cloudy from the presence of pus. This change may occur gradually, or suddenly from the rupture of an infected focus into the pelvis. At this time, the urine may contain a trace of albumen, blood cells, pus cells, and caseous masses. Lumbar pain or soreness may be noted, and an evening rise of temperature is the rule. Later the pain may increase and in a few instances, acute renal colic may be observed from the passage through the ureter of blood clots or masses of caseous or necrotic tissue. When the bladder mucous membrane becomes involved, the frequency is exaggerated, and pain and tenesmus develop. Fever then becomes more constant, the appetite suffers and weakness and emaciation occur. Occasionally blood may appear in the urine in sufficient quantity to be detected by the naked eye. Physical examination at any time may reveal the presence of a tender renal tumor, and in certain rare cases a thickened ureter may be palpated in the loin or as a result of vaginal or rectal examination. Great frequency of micturition, severe tenesmus, and the passage of a few drops of blood at the end of each act, indicate that the disease has extended to the trigone or prostatic urethra. These 620 DISEASES OF THE KIDNEYS AND URETERS symptoms with an inability of the bladder to hold more than an ounce or two of urine strongly suggest an interstitial cystitis. Diagnosis. — The symptoms and signs of renal tuberculosis in the early stage are rarely sufficient to enable one to make a diagnosis. The occurrence of a cloudiness of the urine without history of an acute infection, with slight frequency should always awaken suspicion. If to this is added an evening rise of temperature with blood and pus cells in the urine, and the presence of a tender renal tumor, tuber- culosis is probably present. One cannot, however, feel sufficiently sure of the diagnosis to advise radical surgical treatment, until tubercli bacilli have been demonstrated in the urine. This is not always easy even when all symptoms and signs point to the disease, for as accurate an observer as Rovsing reports that in 205 of his cases he has been unable to demonstrate the presence of bacilli by the ordinary methods. A twenty-four hour specimen of the urine should be allowed to settle, the sediment precipitated by the centrifuge and at least ten slides thoroughly examined. A negative result does not exclude tuberculosis, as inoculation of a guinea-pig often will give a positive result when the microscope fails. Two important facts must next be established, first which kidney is the seat of the disease, and second what is the functional ability of the opposite organ. This is best determined by cystoscopy, cathe- terization of the ureters, and careful chemical and microscopic exami- nation of the separated urines. Intravesical separators should not be employed, as an isolated patch of tuberculosis inflammation on the bladder wall might easily contaminate the specimen drawn from the side of the healthy kidney. Where ureteral catheterization by means of the cystoscope is im- possible, as in certain advanced cases of urethral obstruction, vesical infiltration or ulceration, several other methods may be employed. First, suprapubic cystotomy and direct catheterization of the ureters through the cystotomy wound; second, closed renal exclusion, exposing the presumably diseased ureter in the loin, and affecting temporary closure of the tube by digital pressure, temporary ligature or soft rubber coated forceps as recommended by Mation and FedorofT. This allows the urine from the presumably healthy kidney only to flow outward through the natural passages, and be subjected to the various functional tests; but the method has the objection that urine secreted by a healthy kidney may become contaminated by passing through an infected bladder. Third, open ureteral exclusion as recommended by Rochet and Kelly. This gives more accurate results, for the ureter is opened by a longitudinal cut above the closed segment and the uncon- taminated urine collected and examined. Rovsing's plan is to expose both kidneys and after careful inspection, palpation, and examination of the upper part of the ureters, decide on the kidney most diseased, the probable functional activity of the other, and the operative treatment to be carried out. He reports INFLAMMATORY DISEASES OF THE KIDNEY 621 30 cases examined in this manner, in 24 of which nephrectomy was performed, with recovery in every instance. Prognosis. — This depends largely on the stage of the disease, the amount of tissue involved, and the resistance of the individual patient. Undoubtedly spontaneous arrest of the disease takes place, and the remaining cheesy focus may become inocuous, encapsulated, or calcified. It is often observed in surgical tuberculosis, if the primary or chief active focus of the disease is removed, arrest or cure of the remaining lesions often takes place. For that reason one often advises nephrectomy in cases of advanced renal tuberculosis, even when the ureter and bladder are the seat of definite lesions. Early nephrectomy may be expected to cure from 60 to 70 per cent, of the cases where the opposite kidney is free from the disease. Rovsing in a recent report states that 75 per cent, of his cases are cured, and Israel reports a mortality of 25, 12 per cent, immediate or operative, and 13 per cent. late. Harris has reported one cure and two cases followed by marked improvement where he removed a tuberculous kidney in the presence of secondary involvement of the remaining organ. Treatment. — If in an otherwise healthy individual, tuberculous disease can be accurately located in one kidney, the indications are for nephrectomy at the earliest possible moment. Nephrectomy is also to be advised in cases of early secondary involvement of the bladder mucous membrane. The presence of a quiescent tuberculous focus in the lung, epididymis, or a joint, does not contra-indicate the opera- tion where the renal lesion is the active one, giving rise to toxemia which lowers the patient's resistance. Nephrectomy is occasionally justifiable in cases of secondary in- volvement of the opposite kidney, and in the presence of advanced lesions in other organs, for the relief of suffering. In performing nephrectomy, the author does not advise prolonged or extensive operation, for the removal of the entire ureter even if largely involved. As much of the ureter as can be removed through a generous incision should be excised, the end ligated, cauterized, and dropped back into the retroperitoneal space. In cases of grave sepsis from a mixed infection, resulting in pyonephrosis, nephrotomy with drainage occasionally will be indicated. In these cases the secondary nephrectomy should be performed as soon as the severe toxemia has abated, as dense adhesions rapidlv form, rendering subsequent removal difficult. In inoperable conditions, residence in a mountainous district, especially when surrounded by pines, is of decided advantage, the painful symptoms often disappearing in a surprisingly short period of time. Tonics, cod-liver oil, tuberculin, will be found of benefit in these unfortunate cases. 622 DISEASES OF THE KIDNEYS AND URETERS RENAL CALCULUS. Under certain conditions of the body metabolism solid substances which are normally in a state of solution in the urine are precipitated. This precipitation may take place in the kidney or bladder, and when unaccompanied by any other pathologic condition the minute, sand-like masses are washed away by the urine, a condition usually spoken of as gravel. If in addition to the presence of the precipitated solid particles we have a minute blood clot, bit of mucus, or some other albuminoid substance, the particles are often glued together, forming a small concrement, which may pass away with the urine or remain to increase in size, giving rise to more or less disturbance in the function of the organ by its presence alone or by the inflammatory reaction which it begets. Causes. — Gouty diathesis, sedentary habits, lack of exercise, rich food, alcohol, inflammatory conditions of the urinary organs, and trauma may be enumerated as among the causes of calculus. Varieties. — Primary renal calculi may be composed of uric acid or the urates, calcium oxalate, phosphate of lime, carbonate of lime, cystin, or xanthine. These may occur without pre-existing inflamma- tion of the pelvic mucous membrane. Secondary calculi are composed of ammoniomagnesium phosphate alone or in combination with other salts, and are generally the result of an inflammatory process in the kidney or pelvis. While primary stone may arise at any age the calculus of infancy is generally composed of ammonium urate, that of early adult life of uric acid or the urates, that of later life of calcium oxalate. Pathology. — One or both kidneys may be affected, the number of cases of bilateral stone encountered clinically bring from 10 to 15 per cent. The number of concretions in each may vary from one to several hundred. The presence of a calculus in a healthy kidney gives rise at first only to a catarrhal exudate made up of mucus and white cells, later the mucous membrane of the pelvis becomes per- manently congested and thickened, and the parenchyma slowly develops changes which result in chronic nephritis and sclerosis. In the majority of instances the stones lie free in the pelvic cavity, occasionally one will be found impacted in one of the calyses, and, rarely, a calculus will appear completely imbedded in the renal tissue. If at this stage sudden and complete ureteral obstruction occurs from impaction of the stone, or from any other cause, the kidney becomes functionless and finally atrophies. If the obstruction is incomplete or intermittent, hydronephrosis will develop. Sooner or later in most cases of renal calculus infection occurs. In the majority of instances this reaches the damaged kidney by the blood route. If the process is a virulent one, the acute or fulminating type of hematogenous in- fection may result. If the infection is milder in character, the end result may be a pyelitis, a pyelonephritis, renal abscess, perinephritic abscess or if ureteral obstruction be added, pyonephrosis. If both RENAL CALCULUS 623 ureters become obstructed as a result of calculous disease, calculus anuria develops, which, unless speedily relieved by surgical means, gives rise to fatal uremia. Symptoms. — That renal calculus may exist for a long period of time without giving rise to symptoms referable to the kidney, is abundantly proved by numerous autopsies. In these instances the stone usually occupies a position in the parenchyma of the kidney or is firmly fixed in one of the calices. Movable stone in the pelvis of the kidney almost invariably gives rise to one or more of the fol- lowing symptoms: pain, hematuria, vesical irritability, and pyuria. The pain may be constant, located in the flank, occasionally radiating downward along the course of the ureter; less frequently it extends upward to the shoulder or chest, and rarely it is referred entirely to other organs, as the^testicle, ovary, opposite kidney, or the sole of the foot (Morris). In most cases, however, the pain is paroxysmal severe in character, radiating downward from the flank along the course of the ureter to the given testicle or urethra. Retraction of the testicle may occur, also a frequent desire to urinate with visical and in children rectal tenesmus. During these attacks the suffering often is extreme, necessitating large doses of morphine or the administration of an anesthetic for its relief. The point of greatest intensity of the pain may be somewhat below the kidney. Not infrequently it is located at or near McBurney's point on the right side or at a corresponding point on the left. These attacks of renal colic are generally character- ized by a sudden onset and by equally sudden relief. They are often, but by no means always, caused by the passage of a stone from the kidney to the bladder, for in many cases the stone is far too large to enter the ureter. In these cases the pain is probably due to the forcing downward of the calculus against the ureteral orifice, giving rise to a transitory hydronephrosis. Next to pain, the most characteristic symp- tom of renal calculus is hematuria. The amount of blood lost is exceedingly variable, but, as a rule, it may be said that it is rather more than in renal tuberculosis, and rather less than in tumor of the kidney. The hemorrhage is apt to accompany and follow attacks of colic, and both frequently are occasioned by exercise or riding. While noticeable hematuria is often absent, the microscope is pretty sure to reveal the presence of blood at some period of the disease. In 32 cases of renal or ureteral stone recently reported by the author, hematuria was present in 16. In only 7 of these cases, however, was it present in sufficient quantity to color the urine, so that it was recognized by the patient; in 9 it was found only by the microscope. Vesical irritability, evidenced by frequent and painful micturition, is occasionally present, and is often a misleading symptom, directing the attention of the surgeon to the bladder or prostate. Pyuria may occur as a late symptom. The kidney origin of the pus is indicated by the acid reaction of the urine and by the presence of casts and renal epithelia. 624 DISEASES OF THE KIDNEYS AND URETERS Nausea, vomiting, prostration, cold sweats, and extreme nervous irritability often accompany the attacks of colic. Fever may be present after infection has occurred. When pyonephrosis or peri- nephritic abscess is added, there also may be chills, sweats, and other evidences of general sepsis. Of the physical signs of renal calculus, the only one upon which much reliance can be placed is the presence of a characteristic x-ray shadow. In fact rontgenology has advanced to such an extent during the past half decade, that at present, a negative as well as positive rontgenographic diagnosis of renal calculus can be made in about Fig. 291. — Radiogram of renal stone. (From plate by Dr. L. G. Cole.) 98 per cent, of the cases. Costovertebral tenderness to pressure or percussion is frequently present, and is thought by some authorities to be almost pathognomonic, but in the writer's opinion it is of doubtful value, as it is so often encountered in other pathological conditions. The occurrence of a renal tumor, while occasionally present in cal- culous disease due to a plugging of the ureter, is also more char- acteristic of other conditions. To be of diagnostic value an .r-ray plate must show the structure of the vertebral bodies, the transverse processes to their tips, and the outline of the psoas muscle. In addition to this the shadow made by the calculus should have a distinct and well-defined outline. Of the RENAL CALCULUS 625 various calculi, those showing the darkest shadows are the phosphatic and the calcium oxylate stones, those showing the faintest shadows are composed of pure uric acid. Mixed stones and those composed of the urates and of cystin give shadows which in distinctness vary between the two extremes (Figs. 291 and 292). Diagnosis. — A renal calculus may exist without symptoms or signs, and as all the symptoms of this disorder may occur in other pathologic conditions, an absolute diagnosis without an .-r-ray plate is often impossible. The association, however, of colic, hematuria, and vesical irritability, generally following bodily exercise, riding or Fig. 292. — Radiogram of renal stones. (From plate by Dr. L. G. Cole.) jolting, together with the constant presence of tenderness over the corresponding kidney, in the absence of bladder, prostate, or urethral lesion, renal tumor, or the evidences of tuberculosis, would render the diagnosis of renal calculus highly probable. If, in addition to this, the urine collected from the affected side gave evidences of pus, blood, or crystals, while that from the opposite kidney was normal, the probability would be accentuated. The demonstration of a distinct shadow in an a>ray plate corresponding to the position of the affected kidney would render the diagnosis practically certain. It is rare, however, to encounter cases presenting such an association of symptoms. The constant presence of one or more of these symptoms 40 626 DISEASES OF THE KIDXEYS AXD URETERS or sign-, it of sufficient severity to interfere with the health and comfort of the individual, if not relieved by hygienic or medical means, would justify an exploratory nephrotomy, even where it was found to be impossible to obtain the confirmatory evidence of an x-ray plate, and if no stone was found, in all probability some other lesion would be discovered and the patient relieved. Prognosis. — Although a stone in the kidney may remain symp- tomless for a long period of time, and apparently occasion no serious mischief, still in the great majority of instances it eventually gives rise to infection and other lesion which lead to destruction of the organ or the life of the individual. Treatment. — Prophylactic treatment should be instituted in all cases in which a tendency to the formation of stone is evidenced by the passage of gravel. This should consist in regular exercise, the avoidance of rich food and alcohol, and the daily ingestion of large quantities of water. The alkaline diuretics may be employed if there is constant hyperacidity of the urine. The treatment of an attack of renal colic should consist in a hot bath, copious draughts of water, morphine subcutaneously or the inhalation of chloroform. In the presence of symptoms pointing strongly to renal calculus, thf treatment should be early exploratory nephrotomy or pyelotomy, and removal of the stone if present. The operation is practically without danger if undertaken at an early period, before the renal function has been seriously compromised by infection or extensive destruction of the secreting substance. To delay operation in the hope of causing the stone to disappear as a result of treatment by mineral waters or medicine, is but to invite disaster and to postpone operation to a period when the conditions are far less favorable, as the mortality following nephrotomy for pyonephrosis, and nephrec- tomy necessitated by complete disorganization of the kidney, renders these operations far more formidable procedures. The technic of nephrolithotomy, nephrotomy, and nephrectomy is de-cribed on page 641. Calculus Anuria. — Complete anuria from calculous disease may occur iiuder the following conditions: first impacted calculus in both ureter>: second impacted calculus in one ureter, the other kidney being congeni- tally absent, previously removed or functionless from tuberculosis or some other non-calculous disease; third calculus impacted in one ureter, the other ureter being occluded by inflammatory stricture, tuberculous ulceration, new growth, or a surgical ligature. Symptoms. — The symptoms of this condition are pain, the occurrence of complete suppression of urine, and later the symptoms of progressive uremia. The pain usually is severe and at first resembles the ordinary renal colic, later it changes to a moderate constant aching pain in the loin, which gradually disappears as the symptoms of uremia develop. While the pain and costovertebral tenderness generally indicate the side of the recent obstruction and consequently the potentially TUMORS OF THE KIDNEY AND SUPRARENAL GLAND 627 active kidney, this should if possible be confirmed by an .r-ray plate, cystoscopy and ureteral catheterization. Prognosis. — The prognosis - in calculous anuria is grave; in only about 20 per cent, of the cases has the condition been relieved spontaneously. If unrelieved death takes place in from eight to twenty days in the great majority of cases, although 111 and Miningham have recently reported a success in which operation was not performed until the twenty-third day. Treatment. — The treatment should consist in exploratory nephrotomy or ureterotomy, with removal of the obstructing calculus. TUMORS OF THE KIDNEY AND SUPRARENAL GLAND. Both benign and malignant tumors occur in the kidney. In the older text-books, sarcoma, carcinoma, and adenoma are spoken of as those most frequently observed. Since the classical article by Grawitz, published in 1883, in which he called attention to the fre- quency of tumors arising from adrenal rests, a great deal of study has been given to these neoplasms, which has resulted in a decided change in nomenclature and an entirely new conception of the pathology of renal growths. Regarding frequency, Watson states that the pathologic records of the Boston City and Massachusetts General Hospitals for the past ten years show that considerably more than 50 per cent, of all renal tumors encountered could be classed as hypernephromata. Benign Tumors. — Benign tumors of the kidney are rare. Papillo- mata occur in the pelvis, and grow, as a rule, slowly. Like papillomata of the bladder, they have a strong tendency to degenerate into epithelio- mata. Adenomata are occasionally encountered arising from the renal parenchyma. They are generally encapsulated, but prone to malignant change. Angiomata may arise from the papilla? and give rise to copious hemorrhage. Lipomata, fibromata, myxomata, and dermoids have been observed, but are exceedingly rare. Malignant Tumors. — Malignant tumors of the kidney are much more frequent than the benign varieties. Hypernephromata. — These growths are of frequent occurrence, and arise from small aberrant masses of adrenal tissues beneath the capsule or imbedded in the substance of the organ. They appear as circumscribed yellow or reddish nodules beneath the kidney capsule, or as irregular nodular outgrowths involving a part of or the entire kidney. They may grow slowly, become apparently arrested, or at any time take on a rapid growth and reach an enormous size. The disease not infrequently extends into neighboring veins, and may give rise to an irregular metastasis. These metastases occur in any organ or tissue of the body, but appear more frequently in the bones and lung. The metastatic deposits preserve the histologic structure of the original growth. They rarely involve the lymphatics. 628 DISEASES OF THE KIDNEYS AND URETERS The tumor may remain for years as an innocent growth, but at a later period it almost invariably exhibits well-marked evidences of malignancy. Like normal adrenal tissue, these tumors have the power of changing the blue reaction of starch and iodine into a pale pink color. A knowl- edge of this fact may enable one to make a rapid diagnosis at operation. Sarcomata. — Sarcoma occurs most frequently in children under five and in adults between twenty and fifty. The growth, if of the small round-cell variety, is rapid, and the tumor may attain a large size, sometimes occupying one-half or more of the abdominal cavity. In the less malignant forms the growth is more fibrous in character, slower, and in adults may not prove fatal for two or three years. Carcinomata. — Carcinoma of the kidney occurs in two clinical forms, an infiltrating growth of the parenchyma and an epithelioma of the pelvis. It occurs, as a rule, late in life, and is rapidly fatal. The epitheliomatous type is frequently associated with calculus of the pelvis, which in these cases probably acts as an exciting cause. Tumors having all the histologic characters of an innocent adenoma, in the kidney not infrequently pursue a malignant course, rapid recurrence after removal, and the development of metastasis and cachexia. Symptoms. — The three most important symptoms of renal new growth are hematuria, tumor, and pain. At a late period in the disease there may be varicocele from pressure on the renal vein, and in malignant cases cachexia. Hematuria. — In the majority of cases (50 to GO per cent.) hematuria is the first symptom. It is spontaneous, may occur at night, and often is uninfluenced by exercise or rest. It is generally intermittent, and may be small in amount or very profuse. Tumor is generally the first symptom in children, and in about one-fourth of the cases is the first symptom in adults. The char- acteristics which distinguish a renal tumor from growths in other organs are its position in the loin behind the colon, its characteristic shape, its rounded outlines, the fact that it obliterates the natural curve of the loin, but does not bulge backward, that its mobility is generally limited, and that it is never separated from the spine by an area of resonance. "Renal tumors never invade the bony pelvis, rarely reach the median line, and frequently are separated from the hepatic dulness by a resonant area" (Morris). Pain. — This occurs as a primary symptom in about one-third of the adult cases. It is mild at first, located in the loin, and may radiate to the thorax or groin. It is intermittent, uninfluenced by exercise or rest, and occasionally is severe and resembles. the colic of calculus. Examination of the urine may be negative. Red blood-cells are, however, often found with the microscope when the macroscopic appearances are negative. A marked diminution in the amount of urea excreted is frequently observed as an early symptom (Rovsing). TUMORS OF THE KIDNEY AND SUPRARENAL GLAND 629 As the majority of renal new growths are malignant, and as the prognosis is extremely grave unless the tumor is removed at an early period, it is the duty of the surgeon to investigate at once any ease of symptomless hematuria. Cystoseopic examination and the collec- tion of the urine from each kidney will determine the source of the hemorrhage. Rontgenographic examination not infrequently, will reveal the size, shape and to a certain extent the consistence of a renal tumor. Cysts of the Kidney. — The cysts which occur in the kidney are the simple serous cysts, containing clear or slightly blood-stained fluid; perirenal cysts, containing clear straw-colored fluid and situated near the renal pelvis; the echinococcus cysts, which may reach an enormous size; the dermoid, and the condition described as polycystic kidney. The first four varieties are exceedingly rare. Polycystic Kidney. — Polycystic kidney occurs in both children and adults. In most of the cases the disease is congenital and bilateral. The entire kidney is often transformed into a mass of cysts of vary- ing size, causing atrophy of the secreting substance and symmetric enlargement of the organ. As the condition gives rise to no symptoms other than those of pressure and atrophy of renal tissue, many of these cases reach adult life, and the disease not infrequently is discovered by accident. Sooner or later, however, as the disease slowly progresses, a point is reached when the active renal tissue is not sufficient for the needs of the economy and symptoms appear. If in these cases an unusual demand is made upon the kidneys as a result of some metabolic disturbance or infectious disease, an acute condition of uremia results. Treatment. — In the presence of symptoms pointing to renal new growth an exploratory incision should be made in the loin for purposes of diagnosis. If the tumor is probably malignant, nephrectomy should be performed if the opposite kidney is- known to be functionating satisfactorily and if the growth has not infiltrated the surrounding tissues. Non-malignant solid tumors should be removed by partial nephrectomy. This method is also applicable to echinococcus and other cysts, although they are often cured by incision and stitching the edges of the cyst to the skin. A unilateral large polycystic kidney sometimes gives rise to pain and other symptoms justifying its removal if the other kidney is healthy. Adrenal Tumors. — Hypernephromata or sarcomata may occur as primary tumors of the suprarenal gland. The relations of these glands to the kidneys are so intimate, however, that a differential diagnosis is rarely possible. Cysts. — Adrenal cysts are rare, but have a fairly characteristic symptomatology. They may arise from the degeneration of solid tumors, from the follicles of the gland, from parasitic disease, or from hemorrhage. Virchow described a cystic condition which he 630 DISEASES OF THE KIDNEYS AND URETERS regarded as similar to the cysts of the thyroid, and to which he applied the term suprarenal struma. Symptoms. — The symptoms of a suprarenal cyst are at first indefinite discomfort and a sense of fulness in the upper abdomen. Later there occurs a more or less typical attack of renal colic, the pain starting high up under the diaphragm and radiating downward or toward the umbilicus. These attacks are often accompanied by vomiting and prostration. At a still later period a tumor appears in the renal region, which has a tendency to grow upward and cause pressure on the thoracic viscera. Treatment. — In the treatment of solid malignant tumors of the supra- renal gland, complete nephrectomy is indicated, if the diagnosis can be made sufficiently early to afford a chance of success. Cysts of sufficient size to cause painful symptoms should be removed by means of a lumbar incision when possible. If this is impossible, they should be permanently drained by stitching it to the abdominal wound. THE SURGICAL TREATMENT OF NEPHRITIS. The value of decapsulation of the kidney in chronic afebrile nephritis is still a disputed point. The original favorable reports of Edebohls had the effect of stimulating many surgeons to give the method a fair trial in these otherwise hopeless cases; and while there are some who have become enthusiastic advocates of the operation, and others who unqualifiedly condemn it, the majority of conservative surgeons who have given the method a fair trial agree that in a large proportion of well-selected cases, considerable benefit follows the procedure. While the author has never accomplished a positive cure by this operation, he has observed a number of cases in which a striking and rather unexpected improvement has resulted. This was particularly so in the case of a boy, aged eight years, who for four months had suffered from headache, edema of the face and legs, and ascites. He had been repeatedly tapped, and the legs had been incised for the edema. The urine showed the signs of a diffuse nephritis. After double decapsulation all the symptoms improved rapidly. The edema disappeared, the ascites diminished, the headaches cleared, and his general health improved. The change was so striking, occurred so promptly after the operation, and presented such a marked contrast to the progressive deterioration of health while under medical treat- ment, that it convinced me of the value of the operation. This patient was still alive five years after the operation, but presented unmistakable evidences of chronic nephritis. The Treatment of Acute Nephritis by Decapsulation. — For the past few years the author has been interested in a study of acute hematogenous infection of the kidney, the unilateral type of which was described earlier in the chapter. During the progress of these studies, which were both clinical and experimental, he became con- 77/ a; surgical treatment of nephritis 631 vinced that in a large number of cases, the so-called acute nephritis which so often follows the exanthemata and other septic processes, and is characterized by total suppression or the passage of a very small amount of smoky highly albuminous urine, fever, edema of the face and extremities; and which so frequently ends fatally in a few days, differs in no respect from the acute unilateral type, except for the fact that both kidneys are involved. Pernice and Scagliosi have shown in their experimental work that almost every known form of acute renal degeneration and inflammation, from a slight cloudy swelling of the epithelium to a complete destruction of the organ bv multiple abscesses and purulent inflammation, can be produced by passage of the various pathogenic organisms through its vascular apparatus. This fact was also verified by the author in his experiments. In. a case of postscarlatinal nephritis, with severe unilateral symptoms and evidences of grave and progressive sepsis, but with only a diminished output of urine, the writer performed a nephrectomy which was followed by rapid recovery. An examination of this specimen showed that it contained innumerable septic infarcts and differed in no respect from the other cases of acute unilateral sepsis except that the lesions were non-suppurative, and that cultures taken from a number of the gross lesions could not be made to grow on any of the ordinary media. While many of these cases of so-called acute Bright's disease recover spontaneously, yet it is a well-recognized fact that in a large number of instances the kidneys are seriously and permanently damaged by the attack. In the writer's opinion a large number of individuals who suffer from chronic nephritis in early life can trace the origin of the affection to some such acute process. If decapsulation has often a marked beneficial effect in the chronic terminal conditions of kidney infection, it would seem to the writer probable that a much more satisfactory result would follow if the operation were performed during the acute attack before permanent lesions were produced, and while the kidney tissue was still acutely hyperemic and capable of rapid repair. That this is a fact is evidenced by a number of instances recently reported where decapsulation has resulted in a prompt subsidence of symptoms. That the suspended function of the kidney often can be rapidly restored by this procedure is proved by the following case: A married woman was admitted to the Roosevelt Hospital suffering from right-sided renal pain, some fever, and a diminished secretion of urine. Both ureters were catheterized. From the right only a few drops of smoky urine were obtained in fotty minutes, from the left an abundant flow which was normal in appearance and chemical reactions. Right kidney exposed, and found to be the seat of numerous small elevated lesions (septic infarcts), the fatty capsule was thickened, infiltrated, and moderately adherent. The fibrous capsule was stripped from the organ and the wound closed. Fourteen days later, 632 DISEASES OF THE KIDNEYS AND URETERS after complete healing of the wound, the ureters were again catheter- ized. From both there was an abundant flow, 12 cc. from the right and 15 cc. from the left in twenty minutes. Although the urine from the right kidney showed a trace of albumin, its percentage of urea was higher than that from the left, showing that its function had been practically restored. From these observations the writer feels that the indications for treatment in cases of acute bilateral hematogenous nephritis should be the same as in the unilateral type; and that early decapsulation should be advised whenever medical measures fail to bring relief and a fatal suppression is imminent. The operation, however, should be performed in the shortest possible time, with the minimum of anesthesia and exposure on the table. It is advisable to have both kidneys operated upon simultaneously by two surgeons. Carried out in this way the operation occasionally can be performed in ten or fifteen minutes. INJURIES AND DISEASES OF THE URETER. Prolapse of the Ureter. — This may occur as a congenital or acquired affection, and gives rise to a globular or oval tumor in the bladder. It is exceedingly rare. Wounds of the Ureter — The ureter is occasionally injured in severe traumata, especially in fractures of the pelvis, as a result of gunshot or stab wounds, and in surgical operations. In subparietal injuries extravasation of urine occurs, followed, as a rule, by abscess and evidences of septic intoxication. In open wounds a urinary fistula is established. Symptoms. — In open wounds the diagnosis is easily established by the presence of urine or a urinous odor in the dressings; in sub- parietal ruptures the diagnosis is not so easily made. Localized pain, associated with hematuria, particularly if the latter is inter- mittent, is strongly suggestive of a wound of the ureter. A rapidly progressive swelling and edema of the peri-ureteral tissues in the absence of signs of hemorrhage indicates extravasation and renders the diagnosis practically certain. Treatment. — Longitudinal wounds may be sutured or, if extra- peritoneal, will heal spontaneously if proper drainage is secured. Complete division of the ureter is repaired best by Van Hook's method of end-to-side anastomosis. If the wound is too near the bladder to permit of this method, the distal portion should be securely ligated with silk and the proximal end implanted into the bladder. If these procedures are impossible, implantation of the ureter into the bowel has been suggested, but is more dangerous than nephrec- tomy. Ligation of the proximal portion of the ureter and nephrostomy, as suggested by Watson, is the safest procedure where it is essential to preserve the kidney. INJURIES AND DISEASES OF THE URETER 633 Ureteritis. Idiopathic ureteritis has not been observed. The disease occurs only in connection with an infection of the bladder or kidney, or of both combined. This gives rise to two forms, the septic and the tuberculous. Septic ureteritis exists as an acute or chronic process. In the acute form, the mucous membrane is injected, edematous, and in places eroded. There may or may not be a periureteral edema. In the chronic form the tube is thickened, and if obstruction exists there is dilatation above the point of stricture; or if urethral stricture or prostatic enlargement give rise to the obstruction, the entire tube may be dilated, thickened, and tortuous. In the tuberculous variety the walls may be irregularly thickened, giving a beaded appearance, and the mucous membrane is studded with tubercles or the ulcers resulting from them. If obstruction exists, dilatation is often present. Symptoms. — These differ in no way from those of the accompanying kidney or bladder lesion. The pain is often sharply localized, and tenderness may exist along the course of the ureter, which occasionally may be palpated in thin subjects. Treatment. — Direct application of antiseptic or astringent fluids to the diseased membrane in the septic cases has been practised with success by means of the ureteral catheter or by irrigation from above through a nephrotomy wound. These measures, however, are seldom necessary, as treatment addressed to the renal or bladder disease will usually be quite sufficient. The treatment of the tuber- culous variety should consist in removal when nephrectomy is prac- tised. Complete ureterectomy, however, is rarely practicable at the primary operation, owing to the difficulty in removal of the pelvic portion; nor is this necessary, for experience has demonstrated that a small segment of the ureter, even if extensively involved, seldom causes disturbance if the chief focus of the disease is successfully removed. Obstruction of the Ureter. — Stricture of the ureter may result from the various forms of ureteritis or the pressure of outside tumors or cicatricial bands. It also results from kinking of the ureter and impac- tion of a calculus. When the ureter is suddenly and completely obstructed, atrophy of the kidney results; when the obstruction is partial with occasional periods of complete closure, nephrectasis or dilatation of the renal pelvis occurs. As the dilatation progresses the cortical portion of the kidney is flattened and finally atrophies, con- verting the organ into a large oval thick-walled cyst. If no infection is present and the fluid consists simply of accumulated urine, the condition is called hydronephrosis; if pus is present, pyonephrosis; if the sac contains blood, which occasionally occurs as a result of trauma, the term hemaionephrosis is used. Symptoms. — Symptoms of an acute obstruction of the ureter, as from the impaction of a calculus, are those of renal colic plus localized 634 DISEASES OF THE KIDNEYS AND URETERS tenderness at the point of obstruction. The urine may be diminished in quantity and contain blood. In the slowly developing form of ureteral obstruction the symptoms are those of hydronephrosis which will be described below. Treatment. — This should, if possible, be inaugurated before the process has resulted in nephrectasis. When the symptoms point to an impacted calculus, the ureter should be exposed by a lumbar incision and the obstruction removed. Hydronephrosis. — Hydronephrosis may result from any obstruction to the outflow of urine. If the obstruction is in the ureter from the various causes enumerated above, unilateral hydronephrosis occurs; if due to urethral stricture, prostatic disease, or a tumor of the bladder involving both ureteral orifices, the hydronephrosis is bilateral. Symptoms. — In the early stages the symptoms are those of the obstructing lesion; later, there may be pain and a sense of weight in the lumbar region, and the gradual development of a renal tumor which may grow to an enormous size, filling half the abdominal cavity. Sudden cessation of all symptoms, with rapid disappearance of the tumor and marked polyuria, may take place (intermittent hydroneph- rosis) when the cause of the obstruction is of such a nature that it may be relieved by the growth of the renal tumor, as the twisting or kinking of a ureter in cases of movable kidney. These cases of intermittent hydronephrosis are not at all infrequent, often very obscure in their etiology, and before the days of the z-rays were prac- tically all diagnosticated renal calculus. An important etiologic factor in these cases has recently been shown to be an aberrant arterial trunk to the lower pole of the kidney. This not infrequently lies in front of the ureter and in close relation to it. Forward rotation of the kidney or a slight descent of the organ in these cases gives rise to angulation and obstruction. In two cases of intermittent hydro- nephrosis, the author found the cause to be fixation and partial angula- tion of the ureter from adhesions, the result of an infected neighboring lymph node. It will readily be appreciated that any factor which serves to fix or render stationary the upper segment of the ureter, will favor angulation and obstruction in case of descent or other abnormal mobility of the kidney. One of the most useful aids to diagnosis in these cases of ureteral angulation or obstruction is the evidence furnished by the .r-rays after injection of the ureter and pelvis with a solution of col- largol. Treatment. — If possible, remove the cause of the obstruction. In the event of an aberrant artery to the lower pole being found, this should be double ligated and removed. If due to movable kidney, this should be firmly anchored; if due to an easily located obstruction in the ureter, this should be exposed by a lumbar incision, and if possible remedied. If the point of obstruction cannot be accurately located, expose the kidney, incise, evacuate the fluid, and explore the ureter INJURIES AND DISEASES OF THE URETER 635 with a bougie from the pelvis to the bladder. If the obstruction cannot be relieved, or if the kidney is atrophied, perform nephrectomy. Ureteral Calculus.— While a calculus in its descent from the kidney may become impacted in any part of the ureter, it is most likely to be arrested at its upper extremity, at or just below the pelvic brim, in the pelvic portion near the ischial spine or in the intramural segment. Ureteral calculi are generally oblong in shape, and rarely give rise to total obstruction. The irritation of an arrested calculus gives rise often to ulceration or thickening of the mucous membrane and other coats of the ureter, and produces more or less narrowing of the tube, which may effectively prevent its further progress toward the bladder. Temporary obstruction frequently results from change in the position of the stone or from edema of the adjacent mucous membrane. This gives rise to dilatation of the proximal portion of the tube and renal pelvis. Occasionally such an obstruction becomes permanent and a gradually increasing hydronephrosis results, which may at any time become infected by the blood current or by an ascending process from the bladder or prostate. Symptoms. — That an arrested ureteral stone may give rise to no symptoms is evidenced by the fact that in many instances in which a calculus is known to be lodged in the ureter, long periods of immunity from symptoms occur. Generally, however, stones in the ureter give rise to severe pain, which may be located over the site of the lesion or wholly confined to the kidney region. In the majority of cases typical renal colic occurs, the pain radiating downward from the kidney along the course of the ureter, and extending often to the glans penis or perineum. If the stone is located in the lower portion of the tube, vesical irritability may he present. As in renal calculus, blood is often present in the urine, generally, however, in small amount, detected only by the microscope. Cystoscopy frequently reveals an edema and eversion of the ureteral orifice. The ureteral catheter may or may not be arrested at the seat of the stone. The most reliable sign of a ureteral calculus is the presence in an .'-ray plate of a distinct shadow over the course of the ureter. In about 50 per cent, of the cases examined small round faint shadows are seen in radiographs of the adult pelvis. They are often multiple, and frequently lie somewhat below and to the outer side of the normal postion of the ureter. These may be due to phleboliths, small areas of calcification in the sacral ligaments, or, as demonstrated by the writer on one occasion, to a calcified appendix epiploica of the sigmoid. An x-ray plate taken after the passage into the ureter of a catheter bearing a metal stylet will enable one to determine accurately the relation of these shadows to the ureter. Fig. 293 shows a typical radiograph of an ureteral stone; Fig. 294, the atypical shadows just described. 636 DISEASES OF THE KIDNEYS AND URETERS Prognosis. — The prognosis of ureteral stone in general is unfavor- able, as the majority of stones which have become arrested for any length of time do not pass spontaneously; and as long as they remain in the ureter there is danger of permanent obstruction or of infection of the corresponding kidney. Occasionally small stones after remain- ing in the ureter for several days or weeks will be passed into the bladder. Cabot has reported a ca%e where, in his opinion, such a result followed palpation of the region of the ureter for purposes of diagnosis, and the writer has observed a number of cases where arrested ureteral calculi were demonstrated by the .r-rays and were subsequently discharged through the bladder and urethra. Fig. 293. — Radiogram of calculus in lower ureter. (From plate by Dr. L. G. Cole.) Treatment. — This should depend largely on the size of the calculus as revealed by the .r-rays. Small calculi under half a centimeter in diameter generally pass spontaneously if the ureteral walls are normally elastic. If the stone is slightly larger, situated low down in the canal, and the symptoms are not too urgent, or of long duration, a reasonable time should be allowed for spontaneous relief. During this period the passage of the stone may be facilitated by the ingestion of large quantities of water, the injection into the ureter of bland oil or glycerine, or as recently suggested and successfully practised by Leo Buerger, the dilatation of the lower ureter by means of his electric olive-pointed TUMORS OF THE URETER 637 ureteral dilators. The last two methods, however, require special technical skill in the use of the cystoscope and intravesical instru- ments. When it is not possible to effect removal of the stone by these methods, direct operative attack is indicated. Occasionally a ureteral calculus seen by the cystoscope projecting- from the ureteral orifice can be dislodged by an ureteral catheter. Stones arrested in the intramural segment of the tube can be best removed by suprapubic cystotomy and slitting up the ureteral orifice. All stones situated in the ureter above its junction with the bladder should be approached by the lumbar or inguinal extraperitoneal route. Experience has demonstrated that this method is far superior to any of the older procedures. Fig. 294. — False shadows suggesting ureteral calculi. (From plate by Dr. L. G. Cole.) In difficult cases Gibbon has advocated opening the peritoneal cavity for palpation, both to locate the stone and to assist in its removal by the extraperitoneal route. The technic of this operation will be described at the end of the chapter. TUMORS OF THE URETER. Primary new growths of the ureter are rare. Cysts, papillomata, epitheliomata, and sarcomata have been observed. Secondary involvement of the ureter bv extension from the kidnev is more com- 638 DISEASES OF THE KIDNEYS AND URETERS mon. It occasionally happens that a soft rapidly growing tumor of the renal pelvis will extend through the ureter to the bladder; or, more commonly, in cases of papilloma of the pelvis, the disease may extend downward forming multiple small growths. Symptoms. — The symptoms are pain, hematuria, nephrectasis, and the presence of a tumor in the region of the ureter. Prognosis. — The prognosis will depend on the character of the growth and the extent of ureter involved. Treatment. — The treatment should consist in removal of the diseased portion of the ureter, and, if possible, anastomosis of the divided ends. Occasionally complete nephrectomy and ureterectomy are indicated. OPERATIONS ON THE KIDNEY AND URETER. Before deciding upon any serious kidney operation it is important to determine, if possible, the functional competence of the opposite kidney. This, for obvious reasons, is particularly true in a contem- plated nephrectomy; but it is also desirable to determine this point in other operations which, while they do not remove the diseased organ, may at least seriously interfere with its functional activity for a limited period of time. The methods of determining this are the following: 1. Separation of the Urines. — Obtain the urine from each kidney by means of ureteral catheterization or the use of the Harris segregator, and subject each specimen to a careful chemical and microscopic examination. 2. Cryoseopy. — Determine the freezing-point of the blood serum, which is normally 0.5(3° C. A lowering of this point indicates greater molecular concentration of the blood, and a consequent impaired functional activity of the kidney. A single healthy kidney will serve to maintain the freezing-point of the blood serum at the normal point. 3. The Phloridzin Test. — Inject T V grain of phloridzin beneath the skin of the patient, after complete evacuation of the bladder by catheter. Obtain a specimen of the urine one-half hour after the injection, and another in one hour. If the kidneys are healthy, the first specimen of urine will contain from 0.4 to 0.5 per cent, of sugar, the second slightly less, the average being about 0.06 per cent, less than the first. In disease of the kidney the percentage of excreted sugar is decidedly less, generally about one-half the normal amount, and there is less difference between the first and second specimens. Watson, who has recently investigated the subject, states that in 11 out of 70 cases the findings were not reliable as furnishing indications for operation. 4. The Phenolsulphonephthalein Test. — The patient is directed to drink a pint of pure water. The bladder is next washed out and a catheter left in place. A hypodermic injection of 6 mg. of the drug OPERATIONS ON THE KIDNEY AND URETER 639 is then given; and the time of the first appearance of the drug noted by the occurrence of a pinkish tinge made by the urine dropping from the catheter into a test tube containing one drop of a 25 per cent, solution of sodium hydroxid. The drug should appear in the urine in from seven to ten minutes, 40 to 60 per cent, should be excreted in the first hour, and from 20 to 25 per cent, during the second hour. The percentage of the excreted drug in the one and two hour specimens is accurately determined by diluting the specimen to one litre, rendering it alkaline by the sodium hydroxid solution, and comparing the color with that of a standard solution by means of a Duboscq colorimeter. In the last two methods, separation of the urines by ureteral catheter- ization will enable the observer to form a fairly reliable estimate of the functional competence of each kidney. 5. The Indigo-carmine Test.— Inject 20 cc. of a 0.4 per cent, aqueous solution of indigo-carmine. Fifteen minutes later introduce a cysto- scope and observe the urine flowing from each ureter. If the urine issuing from each ureter is of a deep blue color, and if the flow occurs in strong jets at regular intervals, it is evident that no obstruction exists, and it may be assumed that the kidneys are reasonably healthy. Absence of color in the urine indicates grave secretory disturbance. Of all these methods the most reliable is a chemical and microscopic examination of the separated urines obtained by ureteral catheteriza- tion, particularly the quantitative estimation of urea. It frequently happens, however, that ureteral catheterization is not possible even in expert hands. In these cases careful cystoscopic observation of the results of the indigo-carmine test will afford fairly reliable data. In complicated cases, as pointed out by Edwin Beer, a combination of both methods is of advantage. Cryoscopy gives misleading results at times, for while it will indicate with positiveness the fact that there is sufficient normal secreting renal tissue somewhere in the body, it does not indicate in which organ this tissue is located, and as Rovsing has pointed out in bilateral renal disease, the kidney giving rise to the most painful and distressing symptoms may contain the greater amount of secreting tissue. Beer has also pointed out that a functionallly disturbed kidney may cause a sufficient molecular retention to lower the freezing-point to a .dangerous level (0.60° C.) without there being any organic disease which would contra-indicate operation. Too much reliance should not be placed on any of these methods in determining the advisibility of operation on a septic kidney, as impair- ment of function in the presumably sound kidney may be temporary in character, due to the toxemia induced by the sepsis, and may rapidly disappear after removal of the septic focus. Exposure of the Kidney. — The kidney can be exposed by several incisions. The Posterior Vertical Incision (Edebohls). — The patient should be placed prone on the table, with a folded pillow or cylindric inflated (140 DISEASES OF THE KIDNEYS AND URETERS rubber bag under the abdomen (Fig. 295). The same position more easily can be secured by the use of the kidney rack — now generally attached to modern operative tables. The incision should be along the external border of the erector spina? muscle, dividing skin, superficial fascia, latissimus dorsi, and lumbar aponeurosis. The retroperitoneal space is opened and the kidney exposed by tearing apart the perirenal fat, which will be found in two layers separated by the thin perinephric fascia. The last dorsal and iliohypogastric nerves will be exposed. The kidney generally can be brought out through this incision and thoroughly examined. The Oblique Lumbar Incision. — The patient should be placed in Sim's position, with a large pad under the healthy loin. The incision should begin over the junction of the sacrolumbalis muscle with the last rib, and extend obliquely to or near the anterior spine of the ilium. The skin and fat are divided, the latissimus dorsi and external Fig. 295. — Edebohls' kidney air-cushion, with patient in position for operation. oblique separated or divided, the lumbar aponeurosis incised, and the perirenal fat exposed. If more room is needed, the incision may be extended from below forward and upward toward the umbilicus (Konig), or downward parallel to Poupart's ligament, separating the fibres of the external oblique and dividing those of the internal and transversalis. By these incisions the entire retroperitoneal space can be exposed from the under surface of the liver to the pelvis. The former method is useful in large tumors of the kidney; the latter, in operations upon the ureter. Nephrolithotomy. — Nephrolithotomy is an incision into the kidney for the removal of a calculus. The kidney may be exposed by either of the above-mentioned incisions, the organ and pelvis palpated for evidences of stone, or needled, preferably with a blunt-pointed steel knitting-needle. If a calculus is detected, an incision should be made upon'it through the convex border. After removal of the stone the pelvis should be thoroughly explored with the finger and the patency OPERATIONS ON THE KIDNEY AND URETER 641 of the ureter established by the passage of a bougie. If no stone is detected by palpation or needling, the pelvis may be opened through the cortex and its cavity explored. It not infrequently happens that incision through an hyperemic cortex gives rise to troublesome hemor- rhage. To avoid this the writer has been in the habit of opening the pelvis in the following manner: The thumb and forefinger are placed on either side of the pelvis; a grooved director is next passed through the cortex into the pelvis, a closed pair of dressing forceps passed along the groove in the director into the pelvic cavity and withdrawn partly open. By this method none of the larger vessels are divided. Pyelotomy. — With a view to avoiding the often troublesome hemor- rhage in making an incision through the vascular renal cortex, the cavity of the pelvis may be opened by a direct incision through its wall, avoiding thereby all injury to the kidney parenchyma. The kidney is exposed preferably by the posterior incision, the organ delivered and the posterior wall of the pelvis freed from fat. The entire sinus generally can be palpated by the finger, invaginating the pelvic wall. If a small or moderate sized calculus is detected, the pelvis is opened by a longitudinal or transverse incision, and the stone extracted; after which the opening into the pelvis is closed by plain catgut sutures and a layer of perirenal fat stitched to the line of incision. This operation, in the author's opinion, is to be preferred to cortical nephrotomy in stones of moderate size, where the pelvis can be readily exposed. Nephrotomy. — Nephrotomy is an incision into the kidney for the evacuation of an abscess or the relief of nephrectasis. In opening the pelvis of the kidney through its convex border it is desirable to make the incision in the manner just described. In certain rare instances it is desirable to open the pelvis widely or expose the entire interior of the kidney parenchyma by a longitu- dinal incision. If the incision is made with the blade of a knife, from without inwards, the danger of a fatal hemorrhage is considerable. Cullen has recently shown that incision from within outwards by means of a silver wire carried longitudinally through the organ on a straight or curved blunt pointed liver needle, will greatly reduce the amount of hemorrhage, provided the section is made at or near Brodel's area of lessened vascularity. This in the majority of kidneys lies about half an inch posterior to the midline of the cortical border. Often it can be determined by the shape of the kidney whether this avascular line lies normally behind, or in front of the cortical border. In normal cases (75 per cent.), the anterior surface of the kidney is rounded, the posterior surface flat. In these cases the posterior lip of the sinus is notched and the pulsating arteries can be felt at the anterior border of the hilum. In 25 per cent, of the cases, however, the anterior surface is flat and notched while the posterior surface is rounded. In these cases the posterior half has the greater blood supply and the anemic line is just anterior to the cortical border. 41 642 DISEASES OF THE KIDNEYS AND URETERS Nephrectomy. — Nephrectomy may be accomplished through a lum- bar incision, or by means of the transperitoneal route. The former method is generally to be preferred. The kidney is exposed best by the oblique lumbar or Konig incision, the pedicle isolated, the vessels ligated separately or in two masses by means of strong ohromicized catgut, and divided. The ureter is ligated separately, and after division touched with pure carbolic acid or the actual cautery. In tuberculous or septic disease of the ureter it should be freely exposed and as much removed as possible. The wound should be closed by layer suture with drainage. If the abdominal route is to be employed, a long vertical incision is made near the outer border of the rectus muscle separating its fibres. After opening the peritoneal cavity the parietal peritoneum is divided along the outer border of the colon, and the gut pushed well toward the median line, exposing the kidney and its pedicle. After abdominal nephrectomy drainage should be established through an incision in the loin. Fig. 296. — Showing two of the four suspension sutures passed through reflected and attached layers of capsule proper, without penetration of kidney substance. The two companion sutures, passed on the opposite face of the kidney, are not shown. Nephropexy. — Nephropexy is practised for the purpose of anchoring a movable kidney. This is accomplished best by means of the method of Edebohls through the posterior vertical incision. After the organ is exposed, its fatty capsule should be dissected away and the fibrous capsule stripped backward from an incision along the convexity. The quadratus lumborum fibres are exposed by a division of its sheath. Four ehromicized catgut sutures are then passed longitudinally through the folded capsule, two on each side. Both ends of each suture are next passed outward through the muscle and divided lumbar aponeurosis, those from the posterior portion of the renal capsule emerging through the posterior lip of the incision, those from the anterior layer through the anterior lip. On drawing these four sutures tight, the denuded convex border of the kidney is brought in contact with the edges of the wound and the exposed fibres of the quadratus muscle. The muscular and aponeurotic layer is next closed by interrupted sutures, after which the fixation sutures are tied parallel OPERATIONS ON THE KIDNEY AND CltETER (143 with the wound. The skin should then lie sutured with silk or silk- worm gut. The patient should he kept in bed three weeks (Figs. •>\H\, 297, 2<)v>. Fig. 297. — The kidney has been replaced and the ends of the suspension sutures have been brought through the abdominal wall, emerging on the outer surface of the latissimus dorsi. The fibres of the muscle have been separated from each other, not cut, in making the incision. Pig. 298. — Suspension sutures and sutures closing deep parts of wound tied. Ureterotomy and Ureterectomy. — Ureterotomy is indicated for the removal of a calculus; ureterectomy, for tuberculosis or new growth. 644 DISEASES OF THE KIDNEYS AND URETERS The ureter in its upper portion may be exposed by the oblique lumbar incision. The middle portion of the ureter may be exposed by an extension downward of the oblique lumbar incision to the iliac region, and retracting the peritoneum well toward the midline, exposing the psoas muscle. To expose the lower or pelvic portion of the ureter several methods have been suggested. The simplest and safest is the iliac extraperitoneal route. An incision is made parallel with Poupart's ligament from a point two inches above the anterior superior spine of the ilium to a point about one inch above the external abdomi- nal ring. This divides the skin and superficial fascia. The aponeuro- sis ofjthe external oblique is split, and the internal oblique and trans- Fig. 299.- -Uretro-ureteral anastomosis, end-in-side implantation (Van Hook's method: a, first step; b, second step; c, completed operation. (Bryant.) versalis divided transversely, exposing the subperitoneal fat. The peritoneum is next separated from the iliac muscle and side wall of the pelvis toward the midline and held by broad retractors. The ureter generally will be found attached to the retracted peritoneum, and can be easily separated and palpated to its entrance into the bladder. In ureteral calculus it is desirable, if possible, to push the stone upward and remove it through a longitudinal incision in the healthy ureteral wall. Such a wound in the ureter may be united with fine silk or catgut sutures. In the lumbar region the ureteral wound may be left unsutured if adequate drainage is provided. For the removal of the entire ureter in the female, Kelly advises the combined lumbar and vaginal method. OPERATIONS OX THE KIDNEY AND URETER 645 Uretero-ureterostomy. — Uretero-ureterostom}- is an operation for divided ureter. Carrel in his experimental work has employed end- to-end suture of the divided ureter, using fine silk and the technic described for arterial or venous anastamosis. He finds the method satisfactory where the ureter is fairly large, but in smaller animals stricture has almost invariably followed. To one unaccustomed to such work, the method of Van Hook would be simpler and perhaps less likely to be followed by stricture. Ligate the lower segment of the ureter with strong silk, make a longitudinal incision into the tube just beyond the ligature, and draw the upper segment through this opening by means of a loop of catgut passed through the tip of the upper end, and then inward through the incision and outward through the healthy ureteral walls beyond the incision. This is tied, and one or two other sutures' inserted about the line of junction, or the union protected by means of a fold of peritoneum (Fig. 299). If there is considerable loss of ureteral tissue and the ends cannot be approxi- mated, the kidney may be loosened from its attachments and brought downward in the loin until the ends meet (Bovee) . Implantation of the Ureter into the Bladder. — Implantation of the ureter into the bladder must be undertaken if the distal end is too short to admit of anastomosis. Ligate the distal end and make an incision into the bladder near the ureteral orifice, draw the upper segment of the tube into the bladder by means of a loop of catgut as in Van Hook's method of anastomosis, introduce a few interrupted sutures at the line of union, and protect with a fold of peritoneum or omentum. CHAPTER XXIII. INJURIES AND DISEASES OF THE BLADDER AND URETHRA. CONGENITAL MALFORMATIONS OF THE BLADDER. Exstrophy. — This is a failure of union of the two lateral halves of the anterior wall of the bladder and the overlying soft parts, which results in exposure of the posterior wall of the bladder with its ureteral openings just above the pubes. The condition has been attributed to an early arrest of development or to an intra-uterine rupture of the // Fig. 300. — Exstrophy of the bladder combined with epispadias: B, posterior wall of the bladder; U, U, orifices of the ureters; H, H, inguinal hernia on each side. (Tillmanns.) bladder wall. The malformation is apt to be associated with a failure of union of the pubic arch, and a condition of complete epispadias in the male and a bifid clitoris in the female (Fig. 300). In the milder forms of the deformity the genitals may be normal, and only a fissure in the anterior wall of the bladder may be present. Occasionally the fissure is limited to the abdominal wall, through which a perfectly closed bladder may protrude. In its worst form the malformation is a distressing one, rarely capable of correction. The urine flows over the abdomen and thighs, excoriating the skin and keeping the patient and his clothing constantly wet and offensive. The exposed mucous surface becomes inflamed, sensitive, and easily bleeds. INJURIES OF THE BLADDER G47 Treatment. — The treatment of this condition consists in three methods: first, cleanliness and the use of some closely fitting rubber receptacle to collect the urine and avoid soiling the clothing; second, an attempt to repair or reconstruct the anterior bladder wall by plastic operation; and third, to divert the course of the urine elsewhere, remove the mucous membrane, and promote cicatrization by skin- grafting. In case of simple fissure, closure often may be accomplished by freshening the edges of the cleft, and subsequent layer suture as in other bladder fistula?. In more aggravated cases extensive plastic- operations are necessary to construct an anterior wall to the bladder. For this purpose flaps are taken from the abdominal wall, thighs, prepuce, or scrotum, turned inward, so that the cutaneous surface will be united with the mucous membrane and form the inner lining of the newly constructed reservoir. The raw T surface of this flap is then to be covered by additional flaps or skin-grafts. The results are rarely satisfactory. If the ureters are to be implanted into the rectum or sigmoid, the abdomen is opened above the bladder in the median line, the two ureters ligated near the bladder wall, their proximal portions dissected free and implanted into an adjacent loop of the sigmoid by the method of Van Hook, described above. Numerous other methods have been proposed, including that by Trendelenburg, who suggested division of the sacroiliac joints and crowding the pelvic halves together, thereby converting the exposed mucous surface into a longitudinal sul- cus, which later could be easily closed. While some measure of success has occasionally followed all of these methods, the condition of these unfortunate patients, at best, is deplorable. The author is inclined to believe that the most rational plan to follow in the graver cases is that suggested by Watson, to perform double lumbar nephrostomy, ligate, and divide the ureters, and close the abdominal defect by removal of the mucous membrane, this to be followed by skin-grafting or a plastic operation. Other congenital malformations are: double bladder, by a vertical septum or transverse constriction: diverticula of the mucous membrane alone or with the muscular wall; and a patent urachus through which urine may be discharged at the umbilicus. INJURIES OF THE BLADDER. Contusion.— Contusion of the bladder may occur from any injury which results in a contusion of the lower abdomen or fracture of the pelvis. It also may occur as a result of the careless use of sounds, catheters, or other instruments. The symptoms of a contusion of the bladder may be hematuria and temporary vesical irritability. As a rule, no treatment is required other than rest. Penetrating Wounds. — Penetrating wounds of the bladder may result from gunshot or stab injuries through the lower portion of the 648 DISEASES OF THE BLADDER AND URETHRA abdominal wall, from wounds through the tissues of the perineum, from the unskilful use of urethral or bladder instruments, or from accidental incisions during the performance of surgical operations on neighboring structures. As the symptoms and treatment of these rare injuries are similar to those of the more commonly observed ruptures of the bladder, they will be considered in connection with the latter in the following section. Rupture of the Bladder. — This injury may result from a blow on the lower abdomen when the bladder is full, from fracture of the pelvis with or without penetration of a spicula of the broken bone, or from simple overdistension from some pathologic condition producing complete obstruction of the urethral canal, especially if there is present in the bladder wall malignant ulceration or a thin-walled saccular diverticulum. Ruptures of the bladder are divided into two general classes, the intraperitoneal and the extraperitoneal ruptures. In the former the rent occurs through the posterior or posterolateral wall, and the extravasated urine passes into the peritoneal cavity; in the latter the injury occurs in the extraperitoneal portion of the viscus and the extravasated urine collects in the prevesical space. Occasion- ally ruptures of the bladder involve both the intraperitoneal and extraperitoneal portions of the vesical wall. Intraperitoneal ruptures are the graver injuries on account of the probable infection of the peri- toneal cavity. In ruptures accompanied by fractures of the pelvis there is, in addition, frequently a rupture of the iliac vessels, with severe hemorrhage and the formation of large retroperitoneal hematomata. Symptoms. — If the rupture is an extensive one, there are symptoms of severe shock: pallor, weakness, a rapid, feeble pulse, cold extremities, nausea, vomiting, giddiness, and cold perspiration. In addition there are severe paroxysmal attacks of pain in the lower abdomen and an urgent desire to pass urine. Efforts to empty the bladder result only in the passage of a few drops of bloody fluid which does not materially relieve the tenesmus, and the introduction of a catheter demonstrates an empty bladder. If the rupture is intraperitoneal, free fluid occasionally may be detected in the peritoneal cavity and the symptoms of general peritonitis soon appear; if extraperitoneal, the extravasated urine collects in the space of Retzius, and appears as an indurated swelling which sometimes may be appreciated by rectal as well as abdominal palpation. The induration also may make its appearance in the buttocks or spread through the inguinal canal into the scrotum. The introduction of a given quantity of boric acid solution through a catheter into the bladder and noting the amount returned, will often serve as a valuable indication both of the presence of rupture and, to a certain extent, of the size of the rent. In untreated cases death generally results from peritonitis, uremia, or extensive suppura- tion and sepsis. INJURIES OF THE BLADDER 649 Treatment. — In the presence of symptoms suggesting a rupture of the badder, the first indications are to ascertain if the injury involves the peritoneal portion of the organ; and if not, to locate accurately the extravasation and hematoma. These are best met by a median exploratory laparotomy. The incision should be made between the umbilicus and pubes, and when the peritoneal cavity is opened the presence or absence of blood or extra vasated urine is demonstrated. If the rupture is intraperitoneal, the incision should be enlarged, the rent in the bladder wall united with two rows of sutures, the first of catgut uniting the muscular coat, the second of silk infolding the peritoneum with Lembert or Halsted stitches. The entire cavity of the peritoneum should then be flushed w T ith sterile salt solution and the abdominal wound closed with a small cigarette drain. A catheter may be left for a few days in the urethra to prevent any distension of the bladder and strain upon the suture line. If the rupture is found to be extraperitoneal, the abdominal wound should be tightly closed and an incision made over the prevesical space. This should be freely exposed, if necessary, by a transverse partial division of the attachment of the rectus muscles. The tear in the bladder-wall should be united by two or three layers of sutures, the most external of which should be of chromic gut or silk; the extra v- asated urine and blood should be thoroughly removed, any bleeding points secured by ligature or gauze packing, and perineal drainage established. It frequently happens that rupture is produced by the penetration of a fractured fragment of the horizontal ramus of the pubes, and the resulting wound is large, ragged, severely contused, and situated low down, just above the prostate. Under these conditions accurate suture is difficult, if not impossible, and it is better to unite the wound partly and establish suprapubic drainage. Generous drainage of the prevesical space should be employed in all cases of extraperitoneal rupture, as infection is almost always present, and not infrequently considerable sloughing of the bladder wall occurs, leaving a large rent which heals very slowly. In these cases, as in all cases of suprapubic drainage, the employment of intermittent siphon drainage is of great value, not only in contributing to the comfort of the patient, but by prompt removal of all infected fluids. It occasionally happens in fractures of the pelvis that the triangular ligaments are extensively torn. This often will give rise, through cicatricial contraction, to obstinate urethral obstruction, which develops late, after perineal drainage has been abandoned, and not infrequently prevents closure of the suprapubic fistula. This complication should be met by the use of sounds, and if necessary by external urethrotomy. Long-continued perineal drainage, or the presence of an extensive suprapubic opening, will result in a contraction of the bladder, which may become so reduced in size as to hold only a few drachms of fluid. This condition should be overcome by systematic daily stretching 650 DISEASES OF THE BLADDER AND URETHRA of the bladder by the introduction of fluid through the urethra, the suprapubic opening being closed if possible by digital pressure. The procedure is often a difficult one, but is most important for the future comfort of the patient. Foreign Bodies in the Bladder. — The introduction of foreign bodies through the urethra is of fairly frequent occurrence, especially in females. Hair-pins, pencils, bits of wax or gum, and many other substances have been found by surgeons. In those who habitually use the catheter it sometimes happens that an old or brittle instrument will break during its introduction or withdrawal, leaving one or more inches in the bladder. These foreign bodies give rise to cystitis, and may cause ulceration and perforation of the bladder wall; event- ually they become encrusted with phosphatic salts, and cause symptoms identical with those of vesical calculus. Any non-absorbable suture material, especially silk, may act as an irritant and become encrusted with lime salts, forming the starting point of a vesical calculus. It is therefore always preferable to use catgut for the inner row of sutures in all operations on the bladder wall. Treatment. — The treatment is removal either through the cystoscope when possible or through a suprapubic cystotomy wound. DISEASES OF THE BLADDER. Cystitis. — Cystitis is inflammation of the mucous membrane of the bladder. This is an extremely common affection, and is invariably occasioned by the introduction into the viscus of pathogenic micro- organisms, especially in cases where the resistance of the host to their invasion has been diminished by traumatism or other causes. These may gain entrance by an extension upward of an inflammatory process from the urethra, or downward from the kidney, by the introduction of urethral or bladder instruments, by the rupture of an infected focus into the bladder, by the transmission through diseased tissues of bacteria, or by the blood or lyniph channels. Exclusive of the tuberculous form of the disease, the following micro-organisms are, in the order of their frequency, most commonly responsible for the disorder: the gonococcus, the colon bacillus, Streptococcus pyogenes, Staphylococcus pyogenes, Diplococcus urea? liquefaciens, and the typhoid bacillus. In chronic cases anaerobes are frequently found associated with these organisms. Some of these organisms have the power of decomposing urea, setting free ammonia, and thereby rendering the urine alkaline. Certain factors act as predisposing- causes of the disease and serve to prevent resolution after the inflammation has occurred. These are: the presence in the bladder of tumors, calculi or other foreign bodies, and obstruction to the normal outflow of the urine by prostatic or urethral disease. The process often may be limited to the region of the trigone (tri gonitis), or to other special areas of the bladder. If the inflammation is limited DISEASES OF THE BLADDER 651 in the mucous coat, this is thickened and reddened, and minute ulcerations and hemorrhages may occur, especially in cases in which calculi or other foreign bodies are present. Interstitial cystitis and pericystitis occasionally occur as a result of an extension outward through the mucous coat of a severe gonorrheal or septic infection. This results in great thickening of the bladder walls and contraction of the organ, often to the capacity of a few drachms. Symptoms. — In acute cystitis there are localized pain and a frequent desire to urinate. The pain may be constant, as a dull ache or feeling of discomfort over the pubes or in the perineum; or it ma}' be limited to the act of micturition, when it radiates along the urethra, and occurs with greatest intensity at the close of the act, when it is often felt as a scalding or burning sensation. Vesical tenesmus, Or straining to eject the last drop, and a feeling of more to come after the bladder has been emptied, is characteristic of the severer types of the affection, and actual incontinence is often associated with it; these cases also are often accompanied by fever and malaise; the patient becomes exhausted from loss of sleep, owing to the frequent calls to urinate. In the milder forms of the disease there may be only a slight frequency in urination, and the patient may be unaware of the presence of disease until his attention is called to it by his medical adviser. Tenderness on pressure over the pubes and over the base of the bladder or rectum sometimes may be elicited. In all cases of cystitis pus is present in the urine. It may be small in amount, giving rise to only a slight cloudiness, or it may be present in such quantities as to produce a thick, creamy precipitate on standing. In addition to the pus, squamous epithelium, mucus, and blood are often found. If decomposition has taken place, the urine is ammoni- acal, neutral or alkaline in reaction, and contains crystals of the triple phosphates. In the chronic forms of the disease the pain and constitutional symptoms are, as a rule, wanting. Slight frequency may exist; the urine is cloudy, generally ammoniacal, and presents a sediment of a thick, ropy material resembling mucin. Diagnosis. — While pain, frequency of micturition, vesical tenesmus, and pyuria constitute the characteristic symptoms of cystitis, they are also present in other conditions, as pyelitis, posterior urethritis, suppurative prostatitis when the abscess communicates with the urethra, and in seminal vesiculitis. In pyelitis the pain and frequency are rarely severe, and are often absent, the amount of pus is greater than in cystitis, the urine may be acid, is generally albuminous, and bladder epithelia are not in excess. In posterior urethritis the pain, frequency, and tenesmus are, as a rule, more severe, the amount of pus is comparatively small, and the prostatic urethra may be tender to rectal palpation. If the urine is passed into two glasses, the first urine contains more pus than the second, and in addition numerous shreds of rolled-up pus or mucus. In prostatitis with a discharge of pus into the urethra there is generally a history of severe pain, tenes- 652 DISEASES OF THE BLADDER AND URETHRA mus and retention, followed by sudden relief and the appearance in the urine of a large quantity of pus. The enlarged and tender prostate can also be felt by the rectum; bladder elements are not in excess, and the pain, frequency, and tenesmus, if they continue at all, are mild in character. Seminal vesiculitis rarely gives rise to marked pyuria, and in the presence of acute symptoms the enlarged and tender vesicle can always be felt by rectal examination. In acute cystitis cystos- copy is difficult on account of bladder intolerance and often is inadvis- able. The appearance of the bladder mucous membrane is usually characteristic. The changes most frequently found are engorgement and blurring of the bloodvessels, intense reddening and hemorrhages. In the more chronic forms the cystoscope should always be used as an aid to diagnosis. Treatment. — In the acuter forms of the disease rest in bed, the ingestion of a large amount of pure water, the internal administration of urotropin in doses of from 7 to 15 grains two or three times a day, and supporitories of opium or morphine, constitute the early treat- ment. Belladonna is useful to allay tenesmus and the bowels should be kept freely open. If the symptoms do not quickly subside, the bladder should be washed out once or twice each day with a saturated solution of borax or boric acid, followed by a solution of silver nitrate in a strength of 1 to 8000 to 1 to 3000. Or this treatment may be com- bined with the instillation of smaller quantities of a stronger solution. The use of potassium permanganate, protargol, or argyrol is also to be recommended, but they are inferior to the silver nitrate in the majority of cases. These solutions should be introduced through a sterile soft-rubber catheter passed with the greatest gentleness and under the strictest aseptic precautions. Hot sitz baths are often helpful in allaying pain and muscular spasm. In addition to the above treatment, the cause of the cystitis, if still present, must be sought for and removed, as well as any factor which prevents or retards recovery, as stricture, stagnation of urine, etc. Serum and vaccine therapy has been recently suggested in the treatment of cystitis. The bacteriology of the urine should first be carefully studied. The autogenous vaccines give the best results and should be administered either simple or mixed in small frequently repeated doses. The size of the dose should be gradually increased, care being taken to avoid any severe constitutional disturbance. As chronic cystitis is almost always dependent upon some definite cause, as stricture, prostatic hypertrophy, pyelitis, or calculus, the treatment of these conditions is of the highest importance, and should always be associated with the local measures addressed to the bladder. Bacteriuria. — Bacteriuria is a name given to a condition which is characterized by the presence in the urine of large quantities of bacteria, which, however, have little or no tendency to create an inflammation of the mucous membrane of the bladder. Any chronic condition which tends to produce lowered resistance may act as a predisposing DISEASES OF THE BLADDER 653 cause. The bacteria may be remittently or continuously present. The micro-organisms apparently grow in the urine, the contamination taking place from some small focus. This focus is usually located in the kidney, and is due to one or more insignificant septic infarcts, caused by some mild blood infection. Other sources of infection may be found in the seminal vesicles, in a follicular abscess of the prostate, the sinus pocularis, or one of the ejaculatory ducts. From these sources a certain number of micro-organisms are constantly dis- charged into the bladder. The organism present in eighty per cent, of these cases is, according to the observations of Jeanbrau, the colon bacillus; next in frequency is the Staphylococcus albus; Bacillus typhosus, Bacillus subtilis, and the proteus have also been reported. The micro-organisms multiply rapidly, develop toxins which may become a'bsorbed, and give rise to more or less local dis- comfort, mental depression, and general ill-health. The urine is cloudy and often foul smelling. It frequently has a characteristic smoky opalescent appearance caused by the emulsification of its countless bacterial content. On microscopic examination very few pus-cells are found, but large quantities of bacteria are invariably present. The symptoms are rather indefinite; occasionally there is fever, frequency in urination, with more or less pain. More often local symptoms are absent, and only a general feeling of ill-health or neurasthenia may be present. The treatment should consist in finding the original focus and removing it. Washing out the bladder is of no value. If the focus is located in the prostatic urethra, deep injections of silver nitrate and massage may be of benefit. If the focus cannot be found, the system- atic internal use of urotropin often will bring about a cure. Whenever possible an autogenous vaccine should be made and administered. Hematuria. — While hematuria is only a symptom, it occurs so frequently in connection with grave genito-urinary lesions that a brief consideration of its causes may not be out of place. Hematuria may arise from lesions of the urethra, prostate, bladder, ureter, or kidney. In hemorrhage from the anterior urethra the blood flows continuously from the meatus and does not contaminate the bladder urine. Blood from the posterior urethra flows backward into the bladder and does not, as a rule, appear at the meatus. Urethral hemorrhage may be caused by trauma from external violence or from the use of instruments; from new growths or a granular posterior urethritis. It may also occur as a late symptom in malignant disease of the prostate. In these cases, where the source of the bleeding is in the posterior urethra, the bladder urine is uniformly discolored, but the last few drops passed may be almost pure blood. Hemorrhage of the bladder may be due to trauma, external or internal; to hyperacute inflammatory conditions, to calculus, to tuberculosis, to new growth, or to the sudden relief of an extreme retention. The amount of blood, as a rule, is greatest in new growth, 654 DISEASES OF THE BLADDER AND URETHRA least in inflammatory conditions; when due to calculus, the amount is generally between these two extremes. In vesical hematuria the urine is uniformly mixed with the blood, except in the severest cases, where it may be present in such large amount as to produce clots. If the lesion is situated in the trigone, the last few drops passed may be pure, bright blood. Hemorrhage from the kidney may be caused by trauma, inflam- matory conditions, especially the acute hematogenous infections, calculus, aneurism, or new growth. If the hemorrhage is abundant, renal colic is produced from the passage of clots along the ureter. These long, worm-like clots sometimes may be seen in the bladder by the cystoscope, and are occasionally passed during urination. If the amount of blood is small, the urine may be slightly or not at all discolored; if larger in amount, the urine appears smoky; if the hemor- rhage is very abundant, the color is brighter, and ureteral clots are present. All of these conditions are described at length in the other sections. Of the other rarer forms of hematuria, there may be mentioned the hematuria of scurvy, of malaria, of a chronic interstitial nephritis, and that due to parasites. A form of essential hematuria occurs which has been ascribed to small areas of chronic nephritis or erosion of the vessels of the renal pelvis. It is usually unilateral and often ceases entirely after exploratory nephrotomy. Of the parasitic diseases, two are well recognized as being the cause of hematuria, the Filaria sanguinis hominis and theBilharzia hematobia. Filaria Sanguinis Hominis. — This worm is supposed to enter the human body by drinking-water or through inoculation by mosquitos, in the bodies of which the embryos primarily develop. The adult worms inhabit the lymphatics and reproduce each night hundreds of fresh embryos, which may be detected in the blood by the micro- scope. The parent worms occasionally may be found in the lymphatic vessels, but never in the blood. They are long, thread-like, translucent bodies. The female is much larger than the male, and may measure two or three inches in length. The parent worms cause obstruction in the larger lymphatic vessels by their presence alone, or by an inflam- matory thickening which their presence begets. When the thoracic duct or some large mesenteric tributary is thus obstructed, dilatation of the peripheral branches causes extensive lymphedema or lymph- angiomata, which may rupture, giving rise to chylous ascites, chylous hydrocele, or chyluria. Lesions which rupture into the urinary passages may also give rise to an associated hematuria. The disease is common in tropical countries, but rare in the United States or on the continent of Europe. Bilharzia Hematobia. — The disease prevails extensively in Africa, in India, and in a few other tropical localities. Two or three cases have been reported which apparently developed in the central portion of the United States. The Bilharzia hematobia is a fluke 10 to 20 DISEASES OF THE BLADDER 655 mm. in length, the female being larger than the male. It enters the human body by drinking-water. The adult worms inhabit the venous system, particularly the portal. The female deposits large numbers of eggs in the smaller vessels, which eventually cause a rupture of the vessel and the escape of the ova into the tissues, where they give ri>e to various lesions. Most of these lesions occur in the urinary tract, and may be found in the kidneys, the ureters, bladder, and urethra. The lesions, tor the most part, consist in hyperemic patches or papillo- matous granulations. The chief symptom of the disease is an abundant and persisting hematuria. Calculi frequently develop and, in the advanced stages of the disease, inflammatory lesions, abscesses, and urinary fistula?. As in many other parasitic diseases, blood examinations in these show a moderate leukocytosis with a high percentage of eosinophiles. Treatment. — In regard to the treatment of these parasitic diseases, little or nothing can be accomplished by drugs, except to relieve the painful terminal symptoms. In a few instances of filiarisus the finding and surgical removal of one or more parent worms in a mass of dilated lymphatics has greatly relieved the symptoms, and although one can never be sure that other worms are not present, an attempt to find and remove them is justifiable. Tuberculosis of the Bladder — While tuberculosis may occur pri- marily in any part of the genito-urinary tract, there is a growing belief among surgeons that, in the vast majority of instances, it makes its first appearance either in the kidney or the epididymis. From each of these locations it progresses toward the bladder, following in each instance the direction of the fluid current in the ureter or vas deferens. The disease may also reach the bladder by direct involvement through its wall from a diseased prostate. As the route from the kidney to the bladder is shorter and more direct than from the epididymis, and as renal tuberculosis is of more frequent occurrence than tubercu- lous epididymitis, bladder tuberculosis is more frequently a sequel of kidnev disease. As early tuberculosis of the kidney and epididymis gives rise, as a rule, to no painful symptoms, the irritation produced by the secondary lesion in the bladder is often the first indication of the pathologic condition, and for that reason the primary lesion is not infrequently overlooked. The disease, as a rule, is located in the vicinity of the trigone; if secondary to involvement of one kidney, the region surrounding the orifice of its ureter is first invaded. The dis- ease primarily appears in the form of miliary tubercles, which coalesce, forming indurated areas or ulcers with infiltrated borders. These may extend and form larger ulcerated areas, from which shreds of necrotic tissue may be cast off and appear in the urine. Secondary infection with pyogenic organisms is common. The pelvic lymph nodes are usually affected by the tuberculous process. Symptoms. — Tuberculosis of the bladder may remain latent for a long period, and only give rise to symptoms on the occurrence 656 DISEASES OF THE BLADDER AND URETHRA of a secondary infection or source of irritation. Thus the occurrence of an acute gonorrhea or the passage of an unclean sound or catheter may give rise to a cystitis which may awaken a latent tuberculosis and render the diagnosis exceedingly obscure. The symptoms are those of a slowly developing cystitis; frequency in urination, pain at the close of the act, slight tenesmus, and the presence of pus and blood in the urine. These symptoms progressively increase in severity, slowly at first, but more rapidly toward the end. There is, as a rule, a gradual deterioration of the general health, with afternoon fever, occasional sweats, and loss of weight and strength. As the disease progresses the bladder symptoms become more marked, the pain is constant, and the calls to urinate become more frequent until the urine is almost continuously expelled by frequent spasmodic efforts, each of which is accompanied by excruciating pain and tenesmus. An absolute diagnosis of tuberculosis can only be made by the demon- stration of tubercle bacilli in the urinary sediment, either by the microscope or as a result of animal inoculation. In case of doubt several examinations should be made. In the earliest stage of the affection the cystoscope will show an edematous hyperemic area about the mouth of the affected ureter. Later, the disease extends over the trigone and toward the other ureter, and at a still later period characteristic miliary tubercles and ulcerations may be seen. Treatment. — As a rule, all local measures serve only to exaggerate the symptoms and cause the disease to advance with greater rapidity. In the early stages, an out-of-door life among the pines in a high altitude or a long sea-voyage will often produce a rapid and marked improvement in all the symptoms. Not infrequently such patients may live for years under these conditions in comparative comfort; but as soon as city life is resumed the symptoms reappear and the disease progresses. General tonic measures, creosote, cod-liver oil, iron, and arsenic are indicated. Sometimes injections of tuberculin may prove beneficial. If the pain becomes unbearable, permanent suprapubic drainage is to be recommended Early suprapubic cystot- omy with direct application of strong antiseptic agents to the local lesions has been frequently recommended, but the results of this method of treatment are disappointing. While local measures in this disease are of little or no value and render the patient liable to the dangers of secondary infection, brilliant results are often obtained here as in other tuberculous affections by the early recognition and removal of the primary focus. If it can be shown by the cystoscope that the disease is limited to the region of one ureteric orifice, and that the urine from the opposite kidney is normal, nephrectomy will often bring about a cure of the bladder lesion. After nephrectomy, Rovsing recommends the injection into the bladder of a warm solution of carbolic acid, and retaining it for three or four minutes. About 50 c.c. of the solution should be employed and the treatment repeated three or four times. DISEASES OF THE BLADDER 657 Calculus. — Stone in the bladder is a fairly common disease in certain regions. It seems to be more frequently observed in the tropics, possibly on account of the abundant perspiration and consequent concentration of the urine, also in limestone districts, on account of the greater quantity of mineral salts ingested in the drinking-water. It occurs with greater frequency in childhood and old age than in middle life. It is commoner in men than in women. In an aseptic condition of the urinary passages calculi rarely form in the bladder, but are carried downward from the kidney, lodge in the bladder, and gradually increase in size. They may be single or multiple. If cystitis is present, however, calculi may develop in the bladder. The stone may lie in a diverticulum of the bladder wall or a spasmodic contracture of the bladder around the stone may take place giving rise Fig. 301. — Vesical calculus. Weight, 74 grams. to the formation of the so-called hour-glass bladder. The methods of urinary calculus-formation have been described in the preceding chapter, and will not be repeated here. Varieties. — Vesical calculi may be composed wholly of uric acid, in which case they are round or oval, of a dark brown color, and with a comparatively smooth surface; or of ammonium urate, when, as a rule, they are lighter in color; or of calcium oxalate, the mulberry calculus, an exceedingly hard, dark brown or black stone, with a rough, irregular, nodular surface; or of the phosphates (a mixture of phosphate of lime and the triple phosphates), these are white and friable, and form in the decomposed urine of cystitis. It frequently happens that a calculus has a nucleus of uric acid or oxalate of lime, while the outer layers are phosphatic (Figs. 301 and 302). This change 42 658 DISEASES OF THE BLADDER AND URETHRA in the development of a calculus generally indicates the occurrence of a bladder infection. Cystine and xanthine calculi are rare. Symptoms. — The amount of disturbance produced by the presence of a calculus in the bladder varies according to the kind of calculus and the tolerance of the mucous membrane. Thus, a rough heavy stone will, as a rule, produce more irritation than a smooth light one, and a damaged bladder will react more promptly and violently than a healthy organ. Children, as a rule, experience relatively "more discomfort from stone than older people, and active individuals more than those who live a sedentary life. Although cystitis is generally present in patients suffering with calculus, it is almost always the result of infection from without if the calculus originally Fig. 302. — Vesical calculus bisected. developed in a sterile bladder. It usually follows the passage of some instrument for purposes of diagnosis or treatment, and when it occurs it increases to a marked extent the vesical irritability and other painful symptoms. In children the symptoms of stone in the bladder are frequent and painful micturition, vesical and rectal tenesmus, often with prolapse of the mucous membrane of the bowel. The child is restless, nervous, and irritable, cries with pain at each act of urination and is constantly handling the penis or pulling at the prepuce. In adults there is often a preceding history of gravel and attacks of renal colic. If the calculus forms under sterile conditions of the urinary tract, there may be for a long period no symptoms other than a slight diurnal frequency in urination during or following severe physical exertion. As a rule, however, there is vesical irritability, DISEASES OF THE BLADDER 659 evidenced by an increase of frequency of urination, with slight tenesmus and a pain in the glans penis at the close of the act of micturition. These symptoms are aggravated by bodily exercise and by riding, especially over a rough pavement or road ; they are relieved by rest and change of position, and seldom appear at night. Later, hematuria may occur, generally as a result of some unusual exertion, it is usually scanty and observed at the end of micturition. The general health remains perfect and the urine contains little or no pus. If after the introduction of a sound or searcher, or if from any other cause the bladder becomes infected, the clinical picture at once changes; the pain is greatly increased in severity, the calls to urinate are more frequent, and the tenesmus is increased. The symptoms now are present at night as well as during the day,jthe urine contains pus and "blood, and there may be fever and sweats. The patient becomes exhausted from lack of sleep owing to the frequent calls to urinate, and loses flesh and strength. If urethral obstruction exists, the disease may extend upward to the kidneys and give rise to septic pyeloneph- ritis, uremia, and general sepsis. Diagnosis. — An absolute diagnosis of stone in the bladder can only be made by the cystoscope or by touching the calculus with a Fig. 303. — Thompson searcher. metallic sound or searcher. The Thompson searcher (Fig. 303) is the best instrument for this purpose. The patient should lie on a table with the hips raised on a pillow or cushion. The bladder should contain about 6 ounces of sterile fluid. The searcher should be carefully introduced with the beak upward and carried back to the fundus; it should then be turned from side to side, and gently drawn forward and backward until the entire region of the fundus has been thoroughly explored, after which the beak should be turned downward to explore the pocket which often exists just behind the prostate if enlarged. If a calculus lies free in the bladder, contact with the metal searcher will give a distinct click, which can be both felt and heard. It occasionally happens that a stone is lodged in a diverticulum, in which case the most careful examination with a searcher may fail to detect its presence. In these instances the cystoscope will often reveal the nature of the disease after all other diagnostic means have failed. As in other portions of the urinary tract, the z-rays will often demonstrate the presence of a calculus in the bladder. The shadow is usually in the midline when the patient is in the dorsal position and if lateral may indicate that the stone is imbedded in a diverticulum. 660 DISEASES OE THE BLADDER AND URETHRA Treatment. — Except in cases in which the physical condition of the patient is such as to preclude the possibility of any operative procedure, the indication is in every instance to remove the stone. Several methods are at present in use to accomplish this end, each having its advantages and disadvantages, and each applicable to certain conditions of the patient. These will be considered in the order of their frequency of application. Fig. 304. — Bigclow lithotrite. I/itholapaxy, or rapid lithotrity with immediate evacuation of the fragments. This operation consists in crushing the stone by means of a lithotrite (Fig. 304), followed by removal of the fragments with an evacuator (Fig. 305). The patient should be placed on a table with the hips slightly raised; the bladder should be emptied and ounces of warm boric acid solution introduced. The closed lithotrite Fiu. 305. — Chismoro evacuator. should then be carefully passed into the bladder and the angle of its beak allowed to rest in the median line upon the floor of the organ near its fundus. The male blade should then be slowly drawn back- ward while the beak of the instrument is depressed into the most dependent portion of the vesical pouch; the instrument is then closed by pushing the male blade into place. Usually the stone is caught after one or two such attempts; if not, the lithotrite is rotated to one DISEASES OF THE BLADDER 661 side or the other, and the same procedure repeated after first locating the stone with the closed instrument. When the stone is firmly grasped between the jaws of the lithotrite it is crushed by slowly forcing the blades together with the handle screw. This process is repeated many times until the calculus is reduced to small fragments. The lithotrite is then withdrawn and the evacuating catheter intro- duced, and after allowing an ounce or two of the fluid to escape, the evacuating syringe, filled with warm boric acid solution, is attached and from 1 to 2 ounces of fluid forced into the bladder and withdrawn by alternate compression and relaxation of the rubber bull). By this means the fragments are aspirated into the glass receptacle at the bottom of the evacuating syringe. The presence of large fragments which cannot be aspirated through the tube is indicated by their clicking against the tube during the evacuating process. When these are present, the lithotrite is again introduced and these fragments further broken up and evacuated. When the bladder is emptied of fragments, it should be thoroughly cleansed by a careful washing with warm boric acid solution and the patient subsequently treated by diuretics, bladder irrigation, and anodynes if pain and cystitis are present. In this operation care should be taken to avoid injury of the mucous membrane by including it between the blades of the lithotrite and the stone. To prevent this accident, the bladder should be fairly well distended with fluid (not less than 4 ounces), and after the stone is caught the instrument should be freely rotated before crushing. This operation occasionally may be done with cocaine. Chisniore and Swinburne have each reported a series of cases where the operation has been performed in this manner and the patients subsequently treated as ambulant cases. In the majority of instances, however, general anesthesia is to be advised. A small stone may sometimes be removed directly through the evacuator without crushing. Suprapubic Lithotomy. — In this operation the stone is removed through an opening in the summit of the bladder by an extraperitoneal incision just above the pubis. After the usual preparation the bladder is moderately distended with from 6 to 8 ounces of warm boric acid solution, and a vertical incision is made in the median line just above the symphysis pubis. This is carried down between the two rectus muscles to the prevesical space, which is freely exposed by lateral retractors. The fold of peritoneum passing from the summit of the bladder to the anterior abdominal wall is pushed upward if it extends into the field of operation, and the bladder w T all exposed by tearing away the loose areolar tissue and veins with the fingers or for- ceps. Two stout silk sutures are then passed in a vertical direction through the wall of the bladder on either side of the median line knotted, and held upward by an assistant. The bladder is next opened by a longitudinal incision between these two suture retractors and the cavity explored with the finger, after which the stone is seized and withdrawn with forceps. If the bladder is not infected, an attempt 602 DISEASES OF THE BLADDER AND URETHRA may be made to close the suprapubic wound completely and establish drainage by the perineal route. If this is done, the bladder should be united with two layers of sutures, the first of catgut uniting the mucous membrane, the second of silk uniting the muscular and fibrous coats. If the bladder wall is thin, a third row of silk sutures may be introduced, infolding the. other two. The muscles should next be drawn together with two or three catgut stitches and the skin united in the usual manner, a small gauze drain being left in the lower angle of the wound reaching to the preves- ical space, to allow escape of the urine if leakage should occur. If su- prapubic drainage is to be employed, a rubber tube should be introduced, the bladder wound closed tightly about it, and the superficial wound packed with gauze. The disadvantage of suprapubic drainage is that, unless some apparatus is employed to keep the bladder comparatively empty, the dressings are constantly wet, as well as the patient's person and bedding. This, however, can in large measure be prevented by the use of the siphon drainage (Fig. 30G). By allowing the water from the reservoir to flow into the tube very slowly the loop-trap will be filled about once every two or three minutes; as this empties itself it sucks the fluid from the bladder. As soon as the wound begins to granulate the tube may be removed and a smaller one substituted, or it may be left out altogether and the wound allowed to heal. Healing takes place, under favorable con- ditions, in from two to three weeks. Median Lithotomy. — In this operation the bladder is entered through the deep urethra by a perineal incision. The patient is placed on his back, the buttocks drawn well down to the edge of the table (Fig. 307), and the thighs and knees acutely flexed, and held in this position Fig. 306. — Apparatus for siphon drainage of bladder: A, reservoir; B, suprapubic drainage-tube; C, clamp to regulate flow; D, trap which allows intermittent siphonage of bladder. (Dawbarn.) DISEASES OF THE BLADDER 663 by two assistants or by the Clover crutch. A grooved staff (Fig. 308) is introduced into the urethra and held by an assistant, who also draws up the scrotum, freely exposing the perineum. The surgeon, seated in front of the patient, makes a median longitudinal incision in the perineum, and divides the tissues down to the bulb. The groove of the staff is next felt just below the bulb, and the knife pushed through the urethra into the groove and the urethral tissue incised for a distance of about three-quarters of an inch directly backward toward the prostate. A large probe-director is then passed backward into the bladder and the staff withdrawn. The urethra is next dilated by means of a pair of dressing- forceps passed along the director, and later by the surgeon's forefinger, which finally enters the bladder. When the urethra is sufficiently dilated a pair of lithotomy forceps are introduced and the stone removed. A rubber drainage tube is passed into the bladder through the perineal opening and held in place by one or two silk sutures. The external wound is packed. Lateral Lithotomy. — The patient is prepared and placed in the lithotomy position (Fig. 307). The staff is introduced and an oblique Fig. 307. — Lithotomy position. (Roberts.) Fig. 308.— Grooved staff. incision made beginning at the raphe two inches above the anus and carried downward and slightly outward for three inches, the lower extremity reaching a point midway between the lower margin of the anus and the tuberosity of the ischium. This incision divides the 664 DISEASES OF THE BLADDER AND URETHRA skin and subcutaneous fat. The knife is then plunged boldly inward to the groove of the staff at the upper limit of the incision, and, with the cutting edge turned downward, is pushed through into the bladder. As it is withdrawn the deep cut is enlarged downward, care being taken to avoid wounding the rectum. As soon as the knife is withdrawn the finger is passed into the bladder and the stone felt. A pair of lithotomy forceps are then passed into the bladder and the stone removed. After all hemorrhage is arrested a tube is introduced and the wound packed. The tube may be removed in forty-eight hours. As the wound granulates the urine gradually begins to pass by the urethra. Choice of Operation. — Litholapaxy should be employed in middle- aged individuals in the absence of severe cystitis where no urethral obstruction or prostatic disease is present, and where the stone is of moderate size and not too hard to be easily crushed by the lithotrite. Suprapubic lithotomy should be the operation of choice in young children and old men, especially when prostatic enlargement or stricture is present. It should also be employed if for any reason a rapid operation is essential to success, and in all cases of very large stone. Median lithotomy is indicated for small and very hard calculi in middle-aged individuals, and when perineal drainage or exploration of the prostatic urethra is desirable. Lateral lithotomy is now rarely employed. It is occasionally indicated in children if for any reason the suprapubic operation seems unadvisable. Vesical Calculus in the Female. — Vesicle calculus in the female is rare on account of the larger size of the urethra, allowing concretions to pass at an early stage in their development. When present they are frequently phosphatic, and occasionally consist of a deposit of phosphatic salts around some foreign body previously introduced through the urethra. Small calculi may be removed by forceps through the urethra, which easily can be dilated to the size of the forefinger; larger stones should be crushed or removed by the supra- pubic operation. TUMORS OF THE BLADDER. From the most recent reliable statistics Mandlebaum states that only about 0.7 per cent, of all tumors occur in the urinary bladder. Men are affected far more frequently than women, the proportion being 10 to 1. About 65 per cent, are, or eventually become, malig- nant. It is an interesting and well-recognized fact that many tumors which are histologically benign appear clinically to be malignant. It has also been observed that certain types of histologically malignant growths pursue a remarkably benign course, showing no evidence of cachexia or metastasis even after several local occurrences. Of the epithelial tumors, papillomata and carcinomata are the commonest, adenomata and cysts are rare. TUMORS OF THE BLADDER 665 Of the connective-tissue neoplasms, fibromyxomata (polyps), fibro- mata, angiomata, myomata, and sarcomata arc to be considered. Dermoids and ehondromata have been observed, hut ;ire so rare as to be surgical curiosities. Papilloma. — Papillomata may occur as pedunculated or sessile growths, may be hard or soft, according to the amount of connective tissue which they contain, and may be single or multiple. When the softer tumors are placed in water they are seen to consist of large branching processes which float about, giving rise to the term villous tumor. Fibromyxoma. — Fibromyxomata occur almost exclusively in chil- dren, and resemble the more commonly observed nasal polyps. Carcinoma. — Carcinomata occur in three varieties — the epithelioma which may so closely resemble the papilloma in its various forms as to be indistinguishable except by the microscope; the adenocarcinoma, and the fibrous or scirrhous type, the last two commonly have their origin in the prostate. Infiltration of the base of the tumor is usually regarded as a sign of malignancy. Sarcoma. — Sarcoma generally arises in the submucous tissues, may be hard or soft, and generally infiltrates all the tunics of the organ. The majority of the bladder growths arise from the region of the trigone. This is particularly true of the carcinomata, many of which have their origin in the prostate. In multiple papillomata a secondary growth is often found at a point of contact of the mucous membrane with the primary growth when the viscus is empty. Symptoms. — The two characteristic symptoms of tumor of the bladder are hematuria and vesical irritability. As a rule, in innocent tumors the order of their appearance is, hematuria first, frequent and painful micturition later; while in malignant growths the dysuria generally appears first and the hematuria at a subsequent period. Unlike hematuria of calculous disease, bleeding from tumors generally arises spontaneously, often at night. The hemorrhage is more abun- dant in the papillomata, and may completely fill the bladder with clots, producing retention and vesical tenesmus to such a degree that supra- pubic cystotomy will be immediately necessary. Innocent tumors may exist for years without producing symptoms other than occasional hematuria and moderate vesical irritability, and this latter symptom may be absent if the growth is located at a distance from the trigone. Obstruction of a ureter from clogging of its vesical orifice by the growth of a tumor is not infrequent, and results in hydronephrosis. If the growth is situated near the urethral orifice, retention of urine may occur. In malignant growths the symptoms are progressive; the pain is present at first only during micturition, later it becomes continuous; the calls to urinate are increased in frequency, and blood is constantly present in the urine. As the disease progresses vesical tenesmus becomes more marked and rectal pain develops; the urine is expelled by spasmodic effort every few minutes, each act being accom- 666 DISEASES OF THE BLADDER AND URETHRA panied by agonizing pain. The patient rapidly emaciates, becomes chachectic, and finally dies of exhaustion, uremia, or sepsis. Cystitis generally develops in cases of bladder growth, commonly after an instrumental exploration. This may give rise to such an increase in the vesical irritability as to cause an innocent growth to present symptoms strongly resembling cancer. Diagnosis. — In the presence of symptoms indicating the possibility of tumor of the bladder, hematuria, and vesical irritability, one must consider three possibilities: stone, tuberculosis, and tumor. In stone the hemorrhage is practically never spontaneous, is rarely profuse, and is generally the result of some unusual bodily motion; the pain is more acute at the end of micturition, and is felt with greatest intensity in the glans penis. The stone generally can be detected by a searcher. The general health may not be impaired. In tuberculosis the cystitis and progressive loss of flesh and strength are the prominent symptoms; hemorrhage is rarely abundant, but is apt to be fairly constant. The demonstration of bacilli in the urine by the microscope or as a result of animal inoculation establishes the diagnosis. If these two diseases can be excluded, vesical hemorrhage and irritability generally mean tumor, especially if the hemorrhage occurs spon- taneously and is abundant, and there is no other evidence of bladder or prostatic disease. A searcher may detect the presence of a hard, infiltrating, cancerous tumor, but it rarely enables the surgeon to appreciate the presence of a villous tumor, except by provoking hemorrhage. Tumors and large stones may sometimes be palpated by one finger in the rectum or vagina and the fingers of the other hand placed above the pubis. Of all diagnostic means at our disposal, the cysto- scope is the most valuable in determining early the presence of tumor of the bladder, and should be employed as soon as a new growth is suspected, before the presence of constant hemorrhage renders its use impossible. By its use, villous tumors generally may be recognized by the presence of the long, slender processes which float about in the fluid, and by the absence of infiltration of the bladder wall and ulcera- tion. Cancerous growths are generally bulky, nodular, with a sur- rounding infiltration of the bladder wall. They often present a ragged, ulcerated surface. Prognosis. — The chances of a radical and permanent cure in an adult suffering from a tumor of the bladder are not large. Watson has shown that the late results are so unfavorable, both in benign and malignant tumors, that something far more radical in operative technic must be employed if any progress is to be expected. Treatment. — Small benign growths sometimes ma}' be successfully removed by snaring through the operative cystoscope or cauterized through the cystoscope with the galvanocautery or high frequency current. As a rule suprapubic cystotomy should be performed for the purposes of exploration (see Suprapubic Lithotomy, page 661). rUUOHS OF THE BLADDER CI 17 If the tumor is found to be benign, it may be removed by scissors, cutting forceps, or by the hot or cold snare. The surrounding mucous membrane should also be removed and the resulting wound united with previously introduced sutures of chromicized catgut (Figs. 309, 310, 311). If the growth is found to be malignant in character and does not involve the ureteral orifices or trigone, it can be radically removed by excising a portion of the bladder wall. This is best accomplished by the method suggested by Schmidt. He advises a median suprapubic incision, exposure of the extraperitoneal portion of the bladder, and stripping the peritoneum from the posterior and Fig. 309.- — Exposure of papilloma of bladder. (Schmidt.) lateral surfaces. The bladder is then drawn to one side or the other and the diseased area mapped out by intra- and extravesical palpation. The entire diseased area, with a generous margin of healthy bladder wall, is then excised and the resulting wound closed by two or more layers of sutures. When the growth involves the ureteric orifice the ureter is divided close to the bladder and, after removal of the diseased area, implanted in the upper angle of the bladder wound (Fig. 312). Where the disease is more extensive, especially if both ureteral orifices are involved, total cystectomy ma}' be performed with 668 DISEASES OF THE BLADDER AND URETHRA Fig. 310. — Sutures in place. (Schmidt.) Fig. 311. — Appearance after removal of growth and closure of wound. (Schmidt.) TUMORS <>F THE HLADDKH 669 ligation of both ureters near the kidney, and double nephrostomy. In fact, Watson has suggested this operation for all eases of malignant growth of the bladder and for all eases of benign growth which have recurred after primary removal. When this operation has been performed the patients can be kept fairly dry by the use of Watson's lumbar drainage tube and urinal (Fig. 313). Fig. 312. — Excision of the bladder for new growth. (Schmidt.) In some cases of malignant growth of the bladder, especially when arising from the prostate, the best approach is gained by a median intraperitoneal section of the organ, the patient being in the Trendelen- burg position. This allows ready access to the prostate and trigone and renders easy the removal of any amount of bladder tissue in this region. Wlien complete removal is impossible, suprapubic or perineal drainage is indicated as a palliative measure. Recent experience tends to demonstrate that most small benign 670 DISEASES OF THE BLADDER AND URETHRA growths and some malignant neoplasms may be treated with success by the- use of the high-frequency current through the operating eystoscope. Fig. 313. — Watson's Lumbar drainage apparatus. (Watson and Cunningham,) FUNCTIONAL AFFECTIONS OF THE BLADDER. Retention of Urine. — While this is often a symptom of some definite lesion, as stricture of the urethra, hypertrophy of the prostate, the impaction of a calculus, periurethral or prostatic abscess, it not infre- quently occurs as a functional disorder following a surgical operation, or be due to a temporary overstrain of the bladder, to fright, to embarrassment, or to some other purely mental disturbance. As in other forms of retention, the symptoms are an urgent desire to urinate, pain in the hypogastric region, and the presence of a tumor formed by the distended bladder in the median line just above the pubes. In the absence of any pathologic obstruction, urinary retention should be relieved by catheterization. It must be remembered, however, that during an acute or chronic retention the bladder is FUNCTIONAL AFFECTIONS OF THE BLADDER 671 particularly susceptible to infection, and the same precautions should be taken as in the relief of retention due to prostatic hypertrophy, described on page 713. Paralysis of the Bladder.— Paralysis of the bladder may occur as a result of spinal trauma and other pathologic conditions of the brain and cord. Incomplete paralysis, often resulting in irregular attacks of retention of urine necessitating the use of the catheter, is frequently associated with locomotor ataxia. The symptoms of paralysis of the bladder are retention and overflow. The urine collects in the bladder until it is distended to itr fullest capacity, after which it dribbles away through the urethra, producing a condition spoken of as incon- tinence from overflow. The treatment should be by regular aseptic catheterization. Atony of the Bladder. — Atony of the bladder is a condition of paresis of the detrusor muscle, caused generally by obstructive or inflammatory disease of the prostate or urethra, or as a result of tem- porary overstrain of the bladder from enforced voluntary retention. The bladder-muscle is not paralyzed but weakened. The bladder is able to expel a part of the contained urine, but contraction is incom- plete, and a certain amount of urine is constantly present in the viscus which cannot be expelled by voluntary effort. The amount of the residual urine gradually increases until there may be great disten- tion and overflow. The treatment should be by regular aseptic catheterization, which will be spoken of more fully under Prostatic Hypertrophy. It is important whenever possible to discover and remove the cause. Incontinence of Urine. — Incontinence of urine, due to a lack of voluntary control over the sphincter muscle, may result from some pathologic condition of the spinal cord, from some mechanical injury to the neck of the bladder, or it may be of purely nervous origin. In this condition urine constantly flows from the bladder, keeping the clothing wet and the parts irritated or excoriated. This true incon- tinence should not be confounded with the false incontinence from overflow seen in overdistention of the bladder. Nocturnal Incontinence of Children. — This condition, unfortunately quite common among modern children, is a neurosis which is character- ized by an increased irritability of the vesical neck, resulting in the spasmodic expulsion of urine during sleep. The condition is a surgical one, only in that it may be the result of some local irritation, as phimosis, calculus, or some irritating lesion of the rectum. Painful Neuroses. — Painful neuroses of the bladder are occasionally encountered in adults, especially in hysteric women. These conditions are characterized by frequent and painful urination, retention or incontinence, the sensation of a foreign body in the urethra or bladder, great bodily weakness following urination, and often an urgent desire to urinate as soon as the patient is placed in a position where urination is impossible. The condition is of purely medical interest, but is 672 DISEASES OF THE BLADDER AND URETHRA mentioned here for the reason that in its graver forms the neurosis often simulates some important surgical lesion. As a rule, these conditions are characterized by the fact that the symptoms are not constant; that they frequently vary from day to day; that polyuria is generally present, and that they are often relieved by suggestive therapeutics. Treatment. — In all of these nervous disorders of the bladder the treatment should consist in the removal of the cause, if that is pos- sible. If not, regular aseptic catheterization when retention exists, and the wearing of a suitable urinal when incontinence is present. Pneumaturia. — It occasionally happens that air is passed from the bladder with the urine. This phenomenon is due either to the occur- rence of a fistulous tract between the alimentary canal and some part of the urinary tract or, as suggested by BeVan, to infection by some gas-producing organism, especially by the action of B. coli communis on a urine containing sugar. In the great majority of cases the cause is a fistula, and is the result of the rupture of an appendicular abscess into the bladder. In other cases it may be due to seminal vesic- ulitis, to diverticulitis, or to ulceration of the bowel from malig- nant diseases. Trauma occasionally acts as a causative factor and fistula 3 from the kidney pelvis may result from calculus, renal or perirenal suppuration. When large quantities of intestinal matter are discharged into the bladder cystitis may result. The treatment should consist in accurately locating the fistula, measures to effect extravesical closure, and in cases when no fistula exists in careful bladder washing and correction of the bacilluria. MALFORMATIONS OF THE URETHRA. Congenital Absence of the Urethra — Congenital absence of the urethra and atresia at different points in the canal have occasionally been reported; also congenital diverticula, or urinary pouches. These conditions are exceedingly rare, and for their consideration the reader is referred to treatises upon genito-urinary disease. Hypospadias. — Hypospadias is a congenital deformity due to arrest of development or to an intra-uterine injury which results in a more or less complete absence of the inferior wall of the urethra. Three degrees of this deformity are described: the glandular, in which the urethra opens not at the apex of the glands, but on its inferior surface in the space usually occupied by the frenum; the penile, in which the opening is on the under surface of the penis, near its junction with the scrotum; and the perineal, in which the external urethral orifice is located in the perineum. In the last variety there are also a cleft of the scrotum, a rudimentary penis, and often a failure of the testicles to descend, creating a deformity sometimes described as pseudo- hermaphrodism. A moderate degree of hypospadias, in which the opening is situated MALFORMATIONS OF THE URETHRA 673 at or near the glans penis, produces, as a rule, no serious inconvenience. In the severer forms the sexual function is impaired, and urination is sometimes rendered difficult through narrowing of the meatus ami inability to project the stream from the body. Treatment. — The treatment of this deformity is by means of various plastic procedures, each adapted to a certain form of the defect. In the glandular form no treatment is necessary. If the opening i> situated between the glans and the scrotum, Carl Beck employs the following method: The urethral orifice and about one inch of the urethra are dissected free from the corpus spongiosum. The glans penis is then Fi<;. 314. — Beck's operation. • (Watson and Cunningham. Fig. 315. — Beck's operation, and Cunningham.) Watson tunnelled by means of a sharp, thin-bladed bistoury from the apex backward to the original site of the orifice. Through this the elastic urethra is drawn and retained with fine silk sutures (Figs. 314 and 315). For a description of the plastic operations for the severer forms of the deformity, the reader is referred to works on operative surgery. Epispadias. — Epispadias is a congenital malformation resulting in a more or less complete absence of the superior wall of the urethra. The deformity is rarer than hypospadias. When complete, the con- dition is associated with exstrophy of the bladder, absence of the symphysis pubis, and a rudimentary penis. Occasionally the external 43 674 DISEASES OF THE BLADDER AND URETHRA urethral orifice is situated at the root of the penis or on the upper surface of the glans. In these cases the glans or rudimentary penis is cleft or deeply grooved. Some of the incomplete forms may be remedied or improved by plastic operations. INJURIES OF THE URETHRA. Contusions of the Urethra. — Contusions of the urethra may occur as a result of blows or falls upon the penis or perineum. The mucous membrane may be swollen, ecchymosed, and surrounded by a blood clot giving rise to partial obstruction to the passage of urine. Xo treatment is required other than that addressed to the external iniury. Wounds of the Urethra. — Wounds of the urethra may occur from stab or gunshot injuries, from glass cuts, and as a result of various other lacerating traumata. If infected or severely contused stricture is apt to develop. Hemorrhage is often severe and there may be extravasation of urine. Clean-cut longitudinal wounds should be freely exposed and united with fine catgut sutures over a catheter which should be left in situ for a few days; ragged, contused, and irregular wounds should be treated upon the principles laid down for the treat- ment of urethral rupture. Rupture of the Urethra. — Rupture of the urethra is of fairly frequent occurrence. It may be partial, involving either the fibrous sheath or the mucous membrane, or total, involving sheath, mucous membrane and corpus spongiosum. It is important on account of the fact that, if it is unrecognized or neglected, it is apt to be followed by extrava- sation, gangrene, sepsis, and death; also because it is frequently the cause of a subsequent stricture. The injury occurs with greatest frequency in theperineal region involv- ing the bulbous portion of the canal, and is caused by blows, kicks, or falling astride a beam or other hard substance. It may occur in the penile urethra from any injury which forcibly drives the penis upward against the pubic bone, especially if received during erection. It may involve the membranous urethra as a complication of pelvic fracture but is rare in the prostatic portion of the canal. As a rule, it is accom- panied by more or less contusion of the overlying soft parts, but the injury to the urethra is usually caused by its being pushed violently against the pubic bone. The wound is generally a lacerated one, and may completely divide the canal. When the patient attempts to urinate, the urine is forced out into the surrounding tissues, producing more or less extensive extravasation, which, if unrelieved, results in sloughing of the parts, cellulitis, and abscess. Symptoms. — The symptoms of rupture of the urethra are localized pain, hemorrhage, and retention. The pain is moderate in degree at first, but often is greatly increased after efforts at micturition, which give rise to increased hemorrhage and extravasation of urine into the surrounding tissues. Hemorrhage may immediately follow the injury, INJURIES OF THE URETHRA 675 or it may appear only during efforts at urination. Retention may be complete, or any amount of urine may be passed. Absolute retention generally means extensive laceration or a complete transverse rupture of the canal. Extravasation into the anterior perineal compartment, between the deep perineal fascia and anterio'r layer of the triangular ligament, gives rise to a perineal swelling which lies between the rami of the pubis and above a transverse line connecting the two tuberosities of the ischium. If the extravasation is large, the tissues of the scrotum are infiltrated and the swelling appears in the abdominal wall above the pubis. If the extravasation occurs between the two layers of the triangular ligament, the deep perineal compartment, it appears as a deep triangular induration which is limited in extent until it ruptures into the ischiorectal fossa or anterior perineal space. Extrav- asations behind the deep layer of the triangular ligament (from the prostatic urethra) may burrow above the levator ani muscle or rupture downward into the ischiorectal fossa. Abscess, sloughing, and exten- sive loss of tissue result unless the extravasation is speedily relieved by free incisions. Treatment. — The first indication is to relieve the retention of urine when this is present. This should be accomplished by the introduction of a catheter. It will generally be found that a solid silver instru- ment or the gum-elastic coude catheter will be most serviceable; the beak of the instrument should continually hug the roof of the canal during its introduction, as this is the part that is least likely to be injured by the trauma. Prolonged efforts at catheterization should not be made. If a catheter slips easily into the bladder it may be tied in situ, left in place for a few days and the canal subsequently dilated with sounds. If the instrument does not readily pass, the retention, if urgent, may be relieved by aspiration while the patient is being pre- pared for operation. In complete perineal rupture of the urethra an external incision may be made down to the point of rupture and the divided ends of the canal sutured with fine catgut, the wound closed, and a catheter passed to the bladder and tied in. This theoretically ideal method almost never succeeds. The method usually adopted is to remove all bruised and necrotic shreds of tissue, introduce a No. 30 F. perineal drainage tube into the bladder through the perineal wound, and secure it in place by a suture and packing. As soon as the wound begins to granulate the tube can be removed and full- sized sounds passed every second or third day until the perineal wound has healed. If there has been a complete rupture, or if there is much loss of urethral tissue, sounds should be employed at inter- vals throughout life. It sometimes happens after severe injuries that the proximal end of the urethra cannot be found in the perineal wound. Under these circumstances retrograde catheterization through a suprapubic opening may be necessary. In severe lacerations of the penile urethra, external perineal urethrotomy with bladder drainage is indicated, with the use of a full-sized rubber catheter passed from the 676 DISEASES OF THE BLADDER AND URETHRA meatus to the perineal wound and retained in plaee until granulation of the wound is well advanced. This should be followed by the regular use of sounds for a long period. DISEASES OF THE URETHRA. Acute Urethritis. — Acute urethritis is an inflammation of the urethral mucous membrane, characterized by the presence of a purulent dis- charge and painful urination. Although acute urethritis may be occasioned by trauma, gout, rheumatism, typhoid fever, and a variety of other less virulent infections, in 99 of every 100 cases the disease is due to infection of the urethral mucous membrane by the gonococcus, and is acquired by sexual contact. The gonococcus is a kidney-bean-shaped diplococcus usually occur- ring in fours or multiples of four. It is found in the epithelial cells, leukocytes, and free in the discharges. It stains readily with aniline dyes and is decolorized by Gram's method. They usually may be found in large numbers in the pus of an early case, and their presence and identification is of the greatest diagnostic importance. The gonococcus is difficult of cultivation and frequently assumes atypical forms when grown upon laboratory media. When deposited upon the mucous membrane of the meatus they soon spread to the pendulous portion of the urethra and pass through and between the epithelial cells into the submucous connective tissue. They proliferate in large numbers about the ducts of the excretory glands and lacunae from whence it is often difficult to dislodge them. Symptoms. — After a period of incubation which varies from one to fourteen days the patient will experience an itching or burning sensation about the meatus, with slight pain on urination. If exam- ined at this time, the lips of the meatus will be found to be reddened and edematous, and a drop of cloudy mucus can be expressed from the urethra. These symptoms rapidly increase in severity, the dis- charge becomes more abundant, and the pain on urination more acute. The penis is swollen, the prepuce becomes edematous, the glans fiery red and tender to the touch. Erections occur, chiefly at night, and are often exquisitely painful. The discharge becomes thick and creamy, and the pain on urination intense. In uncom- plicated and untreated cases the height of the disease is reached about the tenth or twelfth day. From this time it may continue without improvement for from four to six weeks. It then gradually subsides, and, after a muriber of weeks, the discharge may lose its purulent character and become scanty and watery. In a large number of cases symptoms of posterior urethritis appear early in the disease, generally as a result of some unusual bodily exertion, sexual excitement, or alcoholic stimulation. These are frequent micturition, vesical tenes- mus, and sometimes the passage of blood with the last drop of urine expressed. Of the other complications which are likely to occur in DISEASES OF THE URETHRA 677 cases of acute urethritis, epididymitis is the most frequent: cystitis, prostatitis, seminal vesiculitis, pyelitis, gonorrheal rheumatism, and genera] sepsis arc occasionally encountered, and will be considered in separate sections. Diagnosis. — The occurrence of an acute purulent discharge accom- panied by painful urination and chordee in a previously healthy individual would be sufficient to render the diagnosis of a gonorrheal infection almost certain. The finding of the gonococcus in the secre- tion would remove all doubt. The non-gonorrhea 1 infections of the urethra are, as a rule, much less severe and are short-lived. If the two glass urine test is applied, the presence of pus in the second glass indicates posterior urethritis. Prognosis. — It is possible that an untreated case of gonorrheal urethritis may recover; but recovery under these circumstances must be exceedingly rare, for even under the most approved methods of treatment a fairly large proportion of cases never fully recover. The disease is apt to remain in the glands and follicles of the urethra and prostate, as well as in the ejaculatory ducts and seminal vesicles, for a long period of time. In these situations gonococci develop, and cause a small purulent secretion which from time to time is poured out into the urethral canal and may reinfect its mucous surface, pro- ducing the frequent acute attacks which certain individuals experience as a result of coitus, sexual excitement, or the excessive use of alcohol. Under appropriate treatment the disease may be expected to subside and complete recovery to take place in from four to six weeks. Cessa- tion of discharge may often be effected in from three to ten days, but much more treatment is required before the patient can be said to be cured. Treatment. — Patients undergoing treatment for an acute urethritis should abstain from all alcoholic drinks, excessive bodily exertion, sexual excitement, and highly seasoned food. They should drink copiously of pure water, lemonade, or milk and vichy. Copaiba, sandal-wood oil, and cubebs, when given in sufficiently large doses, greatly diminish the amount of discharge and ardor urina?, but do not cure. They are often useful as auxiliary measures when the symptoms are too acute to permit the use of more effective local treatment. Irrigation of the urethra with mild solutions of mercuric chloride or potassium permanganate has long been a popular method of treat- ing the disease. The urethra should first be cleared of pus by urina- tion, after which from 1 pint to 1 quart of a warm bichloride solution (1 to 30,000) or permanganate (1 to 8000) should be allowed to pass through the anterior urethra by means of the Janet or Valentine irrigating apparatus (Fig. 316). The strength of these solutions may be gradually increased as the symptoms improve. This method, how- ever, has of late been superseded by the use of solutions of the newer silver salts. Argonin, protargol, argyrol, and novargan have been the ones 678 DISEASES OF THE BLADDER AND URETHRA most frequently employed. Swinburne, who has thoroughly tested all of these agents, recommends argyrol in 10 per cent, solution or novargan in a 2 per cent, strength. These are injected into the urethra after urination, and allowed to remain one minute. By this method early cases often can be aborted, and practically all can be controlled. For the treatment of posterior urethritis, the use of these solutions in the deep urethra by means of the Ultzmann or Keyes deep urethral syringe (Fig. 317) will be found effective. The instillations should be made not oftener than once a day; about 10 drops should be used, and the strength of the solu- tion should be somewhat stronger than that used in the anterior portion of the canal. Irri- gation of the entire urethra and bladder from the meatus by hydrostatic pressure by means of the Janet or Valentine apparatus is to be recommended when posterior urethritis is present, but only weak solutions of silver nitrate or potassium permanganate should be employed. After the discharge has lost its purulent character, and after the gonococci have disappeared from the thin, watery secre- tion, irrigations should be suspended and the injection of some astringent solution, as zinc sulphocarbolate, lead acetate, or bismuth suspended in glycerin and water, advised. These injections should be repeated several times a day, always after urination. If the discharge does not readily disappear under this treatment, the urethra should be ex- amined by the urethroscope (Fig. 318) for inflamed follicles or granular patches in the anterior urethra, or by the Swinburne pos- terior urethroscope when the lesions are situated in the deeper portions of the canal. These when present may be treated by direct applications of strong silver nitrate solutions through the endoscopic tube. The use of steel sounds two or three times a week will often be found useful in this stage of the disease. The patient can be pronounced cured only when no discharge exists, and when the urine, after being retained for six hours, shows no free pus or tripper faden containing pus or gonococci. The pros- tate and its expressed material should also be carefully examined. I 2 3 Fig. 316. — Valentine gating apparatus DISEASES OF THE URETHRA 679 Chronic Urethritis. — It frequently happens, even after the most careful treatment, that acute urethritis is followed by a chronic con- dition characterized by the presence of a more or less constant thin mucopurulent discharge {gleet), without pain or other discomfort, and by a frequent return of the acute symptoms of the disease as a result of sexual excitement or alcoholic indulgence. These recurrent acute Fig. 317. — Keyes' deep urethral syringe. attacks may closely resemble a fresh infection, and require the same treatment. Frequently there is no visible discharge and the patient believes himself to be well, and the only sign of the disease may be the presence in the urine of small, thread-like bodies (tripper faden) which represent the minute purulent secretion which adheres to a granular patch or the contents of an inflamed gland or follicle of the urethral mucous membrane. This condition is frequently associated :*w,lu>..i-:.f..a 3J k^ j Fig. 318. — Electric urethroscope. with stricture, chronic seminal vesiculitis, or follicular prostatitis, and requires long-continued treatment with sounds, deep instillations, and local applications. The condition is important chiefly for the reason that the urethral secretions in these chronic cases are often highly contagious, a fact formerly not generally recognized by the profession. 680 DISEASES OF THE BLADDER AND URETHRA At the end of the fifth or sixth week of the disease the presence of a specific antibody can be demonstrated in the blood of a large pro- portion of cases by a complement-fixation test similar in its mode of action to the Wassermann test for syphilis. In the chronic cases with their complications it remains positive in a high percentage of patients, and is of great assistance in both diagnosis and treatment, especially when the gonococcus cannot be demonstrated in the discharges. Vaccine and serum therapy in certain forms of the disease has proven to be of great value. In the very acute stage there is little or no absorption from the anterior urethra, the complement-fixation test is negative, and it is not until the disease has invaded the posterior urethra that complications are apt to arise. It may be used with advantage in the severer complications at this stage such as epididy- mitis, prostatitis, pyelitis, etc.; also at any stage if there is systemic invasion with gonorrheal bacteriemia; here the serum is indicated, for a rapid passive immunity is necessary. In some of the chronic phases of the disease vaccines may be helpful. Perhaps the most favorable results are obtained in the gonorrheal affections of serous membranes, synovitis, tenosynovitis, etc., espe- cially in the acute stage. In these cases vaccine should be em- ployed. It should be remembered that at this time there may be, and often is, a mixed infection, and that the best results are often obtained with mixed vaccines. The serum should be administered in small doses repeated fre- quently (not at long intervals on account of the danger of producing anaphylaxis. The vaccine is best given in gradually increasing doses at intervals of from two to three days. When possible it should be autogenous and, if indicated, mixed with the vaccines of the secondary organisms present. The complement-fixation test furnishes a good indication for vaccine therapy but even when this is negative its use may be indicated in difficult cases. Stricture of the Urethra. — Stricture of the urethra is an abnormal narrowing of the canal due to cicatricial contraction following gonor- rhea, ulceration, periurethral inflammation, or trauma. The cicatrix may completely surround the canal, or it may be limited to a portion only of its circumference. This condition is frequently spoken of as organic stricture, to distinguish it from spasmodic stricture, a con- dition which may produce similar symptoms, but is due simply to a reflex contraction of the urethral muscles. Strictures following gonorrhea may occur at any point in the urethra anterior to the prostate, but are most frequent in the region of the bulb or near the meatus. They are usually mutiple. The}' begin as round-cell infiltrations of the mucous membrane and submucous tissue, which are easily detected in the earlier stages by the bulbous bougie (Fig. 319) or urethrameter of Otis. If subjected to gradual dilatation at this period, they frequently become absorbed and com- DISEASES OF THE URETHRA (is I pletely disappear. If neglected, they become more fibrous in char- acter and yield less readily to the use of sounds. Strictures occurring in the penile urethra rarely contract to such an extent as to cause retention of urine. In the region of the bull) and membranous urethra, however, they are prone to produce great narrowing of the canal, often converting it into a dense fibrous cord tunnelled only by a narrow, tortuous channel. As a result of the resistance offered by such a stricture to the outward passage of urine the urethra behind the stricture is dilated and the bladder hypertrophied. There is often an associated cystitis. The mucous follicles and urethral glands behind such a narrowing partake in the general dilatation, and may be con- verted into minute diverticula, which, if infection be added, may form periurethral abscesses which may or may not retain their connection with the urethral canal. When such an abscess breaks externally a urinary fistula may result. If the stricture becomes too narrow to allow the urine to be forced through, or, what is far more common, if a certain amount of inflammation or edema develops about a narrow but not impermeable stricture, absolute retention of urine results. This quickly, causes extreme distension of the bladder and of the urethra behind the strictured area, giving rise to violent expulsive efforts on the part of the patient, which frequently result in rupture of the urethra and extravasation of urine into the tissues of the peri- neum and scrotum, quickly leading, if not relieved, to gangrene, abscess- formation, and grave sepsis. In narrow strictures of long standing the hypertrophied muscular fibres of the bladder may become sep- arated and the mucous membrane be forced between these muscular bands, forming diverticula or a condition described as a trabecuhrfed bladder. In these chronic cases more or less cystitis usually develops and the bladder becomes small and contracted. If the intravesical pressure is long continued, the ureters and renal pelves may dilate, giving rise to single or double hydronephrosis. If to this condition infection is added, a septic pyelonephritis results. Symptoms. — In strictures of large calibre there may be no symptoms whatever, or there may be only the symptoms of chronic urethritis due to the presence of granular patches behind the point or points of nar- rowing. When the stricture becomes sufficiently narrowed to cause ob- struction to the natural flow of urine, the calls to urinate may be more frequent, and each act of micturition is accompanied by an unusual and sometimes painful effort. The stream is small, twisted, or scattering, and is expelled with little or no force. Frequent micturition caused by an associated chronic prostatitis or cystitis may be present. There may be incontinence of urine in the form of scanty involuntary dribbling after micturition, or urine may escape on exertion. Sexual excitement, alcoholic excesses, and severe bodily strain will frequently cause an aggravation of the condition from congestion of the parts, and tem- porary attacks of partial or complete retention may occur. These attacks are usually associated with severe cramp-like pain in the region 682 DISEASES OF THE BLADDER AND URETHRA of the bladder. There is usually more or less shock. Xo urine or at most but a few drops are passed, and the bladder is found to be dis- tended. These are generally relieved by a hot bath and mild cathartic measures. The attacks of retention gradually increase in frequency until finally one occurs which is not relieved by the ordinary methods of treatment; and unless surgical measures can be promptly employed, extravasation of urine takes place, followed by abscess, sloughing, and urinary fistula. Death not infrequently occurs as a result of septic infection following extravasation of urine or from septic pyelonephritis. Diagnosis. — In a suspected case of stricture the following method may be employed to arrive at a correct diagnosis. The patient is instructed first to pass the urine into two glasses. Pus and shreds in the first glass, the second remaining clear, indicate the presence of a urethritis or an open prostatic abscess. An equal amount of free pus in both glasses indicates cystitis or pyelitis. A large amount of pus in the first and a small amount in the second glass indicate posterior urethritis. The presence, size, and situation of a stricture may also be determined by the careful passage of bulbous bougies beginning with the larger sizes until one is found which will pass. A preliminary meatotomy may have to be performed. Strictures of the penile urethra often can be palpated upon the bougie. French No. 28 or 30 instrument should pass easily through the normal urethra. A stricture may often be accurately located and examined by means of the urethroscope. Care should be used in its introduction to produce no unnecessary trauma. After the anterior urethra has been measured, an attempt should be made to explore the deep urethra by introducing the largest sized steel sound which will pass the anterior portion of the canal. If this is arrested, smaller sizes are attempted until one finally passes to the bladder. If the smallest steel sound will not pass, an attempt should be made with the smaller gum elastic or filiform bougies. After the examination has been completed the urethra and bladder should, if possible, be irrigated with a mild solution of silver nitrate (1 to 10,000) or of argyrol. True stricture of the urethra must be differentiated from spasm of the compressor urethra? muscle and malignant disease of the prostate. When obstruction is encountered, especially in the deep urethra, a rectal examination should be made to ascertain the condition of the prostate. Spasm of the urethra will vield to steady gentle pressure with sound or bougie. Treatment. — If the surgeon is called upon to relieve an attack of acute retention of urine, during the course of the preliminary examina- tion just described, a small bougie or filiform may be passed to the bladder. This should be tied in and left in place to serve as a guide while the patient is being prepared for operation. If for anv reason radical operation is not advisable at that time, the retention will be graduallv relieved by urine passing along the side of the bougie. This will be hastened by the use of a hot bath and the ingestion of hot diuretic drinks. Chloral, grains v-x, every four hours, is useful to allay DISEASES OF THE URETHRA 683 muscular spasm. Twelve hours later the bougie may be removed and replaced by a larger size, and from this point gradual dilatation may be practised. Instruments for dilatation are made of metal or some flexible material. They are usually calibrated according to the French scale in millimetres. In general the smaller the metal instrument the greater is the danger of damaging the urethra. When indicated they should be used with great care and gentleness and only by those who have had some experience in urethral instrumentation. All instru- ments should be sterile and thoroughly lubricated. Several sizes of the gum-elastic, olive-pointed bougies (Fig. .320) should be introduced each day until the stricture is suffieientlv dilated to admit a No. 15 F. steel sound, after which these instruments should be employed. Dilatation should proceed gradually at regular intervals until the stricture has been stretched well beyond 25 F. Dilatation may be complicated bv the production of a false passage, and if this accident should occur instrumentation should be suspended if possible for a few days. Infection may be avoided by care in technic. The passage of urethral instruments is often attended by a transitory faintness, pallor, and malaise; sometimes by actual syncope. These symptoms usually pass off in a few minutes. The majoritv of cases should be kept under observation for several years and the occasional passage of a sound will prevent recurrence. It is surprising how frequently an obstinate gleet will disappear after dilatation, in fact insufficient drainage frequently determines the persistence of a urethral discharge. Cocaine or its derivatives if used as a local anesthetic must be handled with great care. Its effect upon an intact mucous membrane is local and large amounts may be injected without producing any general symptoms. In cases where ulceration is present or especially where a false passage has been created by previous unsuccessful instru- mentation (a not infrequent complication), absorption is rapid and alarming toxic symptoms may follow the injection of comparatively small quantities. In cases in which the distension of the bladder is great and there is danger of extravasation, the use of the Gouley tunnelled sound (Fig. 321) or catheter (Fig. 322) over the filiform may be necessary to relieve the retention quickly. In case no bougie can be passed, the patient should be etherized and placed in the lithotomy position, and after the usual prepara- tion of the parts a sound should be introduced to the strictured area if this is located in the perineal region, and held firmly against the stricture by an assistant. A longitudinal incision is then made in the median line of the perineum, and the various tissues divided until the urethra is reached; this is then opened on the point of the sound, and the edges of the urethral wound held apart by two silk sutures. An attempt is then made to pass a fine probe director to the bladder. If there are no false passages and the 684 DISEASES OF THE BLADDER AND URETHRA case has not been subjected to harsh instrumentation, the posterior urethral opening can generally be found at the apex of a cone made Fig. 319.— Bul- bous bougie. Fig. 320.— Olive- pointed bougie. Fig. 321.— Gouley tunnelled sound. Fig. 322.— Gouley catheter. by drawing outward the urethral margins by the silk sutures. It occasionally happens that a very considerable search is made before finding the posterior opening, and a careful dissection of the perineum DISEASES OF THE URETHRA 685 may be necessary. When found, the posterior urethra should be dilated with dressing-forceps passed along the groove of the director, or by the finger. A full-sized sound is next passed from the meatus to the bladder to insure the patency of the entire canal, after which a No. MO or 32 F. rubber perineal drainage tube should be passed into the bladder through the perineal wound and secured by a single suture. The wound should then be packed around the tube and a T-bandage applied. When the patient is placed in bed the end of the drainage tube should be connected with one leading to a large bottle or reser- voir placed under the bed, and containing a solution of mercuric chloride. Frequent irrigations of the bladder with a bland sterile solution should be practised. If no posterior opening can be found, two methods are open to the surgeon: One of these is known as Cock's operation, which consists in placing the forefinger of the left hand in the rectum and finding the apex of the prostate, then with the right hand passing a thin- bladed knife through the perineal tissues backward and upward exactly in the median line until the dilated posterior urethral pouch is opened just above the tip of the finger in the rectum. The cicatricial tissue which generally is found to intervene between the anterior and poste- rior portions of the urethra is then dissected away, a full-sized sound passed from the meatus to the bladder, and the bladder drained with a No. 32 F. rubber tube as described above. The other alternative is to open the bladder from above (suprapubic cvstotomy), and to pass a sound, catheter, or bougie outward through the internal urethral orifice until it bulges the tissues in the perineal wound. It may then be cut down upon and the case treated as in Cock's operation after partial or complete suture of the suprapubic wound. In cases of extreme urgency it may be necessary to relieve the acute retention before the patient can be prepared for operation. Under these cir- cumstances aspiration of the bladder above the pubes may be practised. While this procedure is only for temporary relief, it may be repeated two or three times if necessary before more radical measures are undertaken. The writer occasionally has seen voluntary urination restored after aspiration, presumably from relief of the hyperemia and edema about the strictured area. In this operation a small needle should be selected and the point introduced just above the symphysis, the direction being at a right angle to the vertical axis of the body. In cases of obstinate deep strictures of larger calibre which will not yield to dilatation, or in which the passage of a sound provokes urethral fever or bladder irritability, and when the patient is unwilling to sacrifice the necessary time, external perineal urethrotomy with a guide may be practised. This is an operation similar to the procedure just described, but is much simpler for the reason that a grooved staff is introduced first and the cut into the urethra is made upon the staff. After division of all strictured tissue the bladder is drained as described above. 686 DISEASES OF THE BLADDER AND URETHRA Anterior strictures of the urethra (within five inches of the meatus) may be treated by internal urethrotomy. General anesthesia is not necessary, but is often desirable. If local anesthesia is employed, about | dram of a 4 per cent, solution of cocaine is introduced into the bulbous urethra by means of a long- pointed syringe, and retained by compressing the lips of the meatus for five minutes. A drop of the same solution is next introduced just below the meatus with a hypodermic syringe. The urethra and glans are then thoroughly cleansed with a solution of mer- curic chloride. The meatus, if strictured, is divided downward to the full size of the canal and the other bands accurately located with bulbous bougies. An Otis dilating ure- throtome (Fig. 323) is then introduced to such a depth that the blade as it emerges is just behind the stricture. The dilator is opened to the full size of the urethra, putting the stricture on the stretch. The blade is then drawn quickly upward and downward twice, the dilator partly closed,' and the urethrotome removed. The hemorrhage is apt to be free for a moment, but soon ceases, after which the canal is irrigated with a hot solution of mercuric chloride (1 to 10,000), a full-sized sound passed, and a dressing of aseptic gauze applied to the penis. Behind the meatus the cut should always be made in the roof of the canal. Before each urination the dressings should be removed and the meatus bathed with the bi- chloride solution. After the bladder is emptied the dressing should be reapplied. During the first few days the patient should remain in bed on account of the danger of hemorrhage, which may occur spontaneously, but generally takes place after urination or as a result of an erection. Gently pressing the lips of the meatus together for five minutes and assum- ing the recumbent posture in bed will serve to check it in the majority of instances. After all operations for stricture full-sized sounds should be passed, at first every three days, later once a week; and if there is a ten- dency to recontraction, at least once a month urethrotome. as long as the tendency is manifest. Fig. TUMORS OF THE URETHRA 687 Urethral Calculus. — Calculi sometimes lodge in the prostatic urethra, behind strictures, or in the fossa navicularis. These occur commonest in children, and may give rise to complete retention of urine. The seat of the impaction is determined by the presence of localized pain and tenderness and by contact with a urethral sound. They may be primary, formed chiefly from continued phosphatic deposit, behind a stricture, or they may be secondary, entering the urethra from the bladder. There is often a previous history of ureteral or renal colic. If they cannot be forced outward or backward, an external perineal urethrotomy should be performed and the stone removed by means of a small scoop or curet. FOREIGN BODIES. Foreign bodies are -not infrequently introduced into the urethra and become impacted. They may determine the presence of a urethral discharge. The diagnosis is made by palpation or with the urethro- scope, and the treatment is removal either with forceps or by external urethrotomy. TUMORS OF THE URETHRA. Epithelioma. — Primary epithelioma of the urethra has been reported but is exceedingly rare. There are about 50 cases reported in the literature. It occurs most frequently in the region of the bulb. The disease is rarely recognized early, the first symptoms generally being retention of urine and the presence of a swelling in the perineum. Hemorrhage and a purulent discharge are present in certain cases and sexual irritability may occur. Examination usually detects the presence of stricture. Involvement of the inguinal lymph nodes is a late manifestation. Treatment.— In the treatment of this condition three methods have been employed: Simple excision with cauterization (Koenig), resec- tion of the urethra (Rupprecht), and amputation of the penis (Miku- licz). Although only a few permanent cures have been reported thus far, they are sufficient to encourage surgeons to advise radical operation in all such cases. Benign Growths — Benign growths of the urethra occur more fre- quently. These are papillomata, which may occur just within the meatus, and a fungoid pedunculated polyp, sometimes found at or near the bulbomembranous junction. Lacunar cysts and cysts of Cowper's gland ducts and the sinus pocularis are occasionally ob- served. These growths rarely give rise to marked symptoms unless they reach a size to produce obstruction. Occasionally they cause localized pain on urination and may give rise to a mucous discharge, paresthesia 3 , and hemorrhage. The diagnosis can onlv be made by the endoscope. The treatment should be excision through an endoscopic tube with cauterization of the removal site. Some of these tumors are highly vascular, and the bleeding following their removal may be considerable. Cysts should be incised and cauterized. CHAPTER XXIV. INJURIES AND DISEASES OF THE PENIS ANT) SCROTUM. INJURIES OF THE PENIS AND SCROTUM. Contusions. — ( Jontusions of the penis differ in no way from contusions in other superficial regions of the body, unless the injury is such as to cause rupture of the corpus spongiosum or one of the corpora cavernosa. Bleeding is usually severe, and in these cases it is often associated with rupture of the urethra. An extensive hematoma may form, which occasionally requires open incision, removal of the clots, and packing. Contusions of the scrotum often result in extensive hematomata, either in the cellular tissue or into the cavity of the tunica vaginalis. When in the latter situation the condition is called hematocele. If of moderate size, these hematomata require no treat- ment other than rest and the application of heat or cold. If large, and especially if they continue to increase in size, they should be treated by free incision, removal of the clots and fluid blood, ligature of any bleeding vessel, and closure with or without drainage. If infection and suppurative inflammation should occur incision and drainage is indicated. The urethra should be examined to detect if present an associated rupture which might lead, if overlooked, to extravasation and retention of urine. Herniation of the penis out of its fibrous sheath or fracture may occur. These conditions are usually associated with more extensive general injuries. Wounds of the Penis and Scrotum — Wounds of the penis and scro- tum not involving the urethra or testicles should be treated as wounds in other locations. INFLAMMATORY DISEASES. Cellulitis. — Cellulitis of the penis or scrotum may follow infected wounds or venereal ulcers. If the infection is mild in character it may resolve under local treatment of acetate and aluminum, or an abscess may form which will require incision and drainage. If the infection is more virulent, or if the resistance of the indi- vidual is lowered, more or less extensive sloughing of the superficial tissues may occur. The treatment should be the same as in other localities. Balanitis. — Balanitis or balanoposthitis is a local inflammation of the skin of the prepuce and the mucous membrane of the glans. It / A' FL . I M MA TOR Y 1)1 SEA SKS I is'. I is predisposed to by phimosis, uncleanliness, and the retention of irritating discharges, and is often associated with subpreputial ulcera- tion or neoplasm. There is itching and burning; thick purulent dis- charge often with swelling and edema of the prepuce. The opposed surfaces of prepuce and glans may present excoriations and superficial ulcerations. When tight phimosis is present the condition may become chronic, giving rise to inflammatory thickening and cicatricial narrowing of the preputial orifice. Treatment consists in separation of the opposed surfaces with removal of the cause and frequent cleansing and irriga- tion of the preputial cavity. When chronic thickening and fibrosis are present circumcision offers prompt and permanent relief. Herpes Progenitalis. — This is of fairly frequent occurrence in individuals with phimosis, and in others whose habits are not cleanly. It also occurs in neurotic subjects often without local irritation. The disease manifests itself by the appearance of a small group of vesicles just behind the corona, which mav also extend to the glans. These soon rupture, leaving small areas of superficial ulceration with a surrounding area of redness. In some instances there are practically no subjective sensations; generally, however, there are itching, burn- ing, and moderate soreness. If a secondary infection occurs, more or less cellulitis may develop with involvement of the inguinal lymph nodes. The treatment should consist in circumcision if phimosis is present, cleanliness, and the local use of iodol or aristol powder. Chancroid or Simple Venereal Ulcer. — This includes all of the venereal sores except the initial lesion of syphilis. The Ducrey-Unna bacillus is believed to be the specific cause. It is usually found in smears and in pus from the inguinal bubo but cannot always be obtained in pure culture. The disease exhibits a tendency to self- limitation and runs an average course of from three to five weeks. The site of election is the coronal sulcus near the frenum, or the pre- putial margin. The lesion varies from a slightly infected abrasion or herpetic ulceration to the most virulent form of gangrenous cellulitis (phagedenic chancroid). The lesions are often multiple and frequently appear at first as one or more small pustules. These may rupture and extend peripherally, and by their coalescence form large sloughing ulcers with irregular undermined edges. The surrounding tissues are reddened and edematous and the inguinal lymph nodes enlarge and become tender. The disease is a painful one and often protracted from the suppuration which frequently takes place in the inguinal lymph nodes (chancroidal bubo). If the case is an early one an attempt may be made by radical cauterization to transform the specific ulcera- tion into a simple one. Nitric acid is the most powerful caustic for this purpose. Expectant treatment consists in cleanliness and the use of antiseptic dressings and washes. If drainage is interfered with by a tight pre- puce a dorsal or lateral slits may become necessary with a plastic 44 690 DISEASES OF THE PENIS AND SCROTUM circumcision after healing has taken place. Single chancroidal infec- tion is relatively rare and it is safer to consider the lesion to he syphilitic until proved not to be so. Chancre. — Chancre, or the initial lesion of syphilis, is described on page 61, in the section devoted to Syphilis. It must be remembered that mixed venereal ulcers are frequently observed where the patients have been exposed to both kinds of infection. In these cases the early appearance of the lesion may be character- istic of herpes or of chancroid, the typical syphilitic induration develop- ing only after the lapse of two or three weeks. One should, therefore, be guarded in prognosis in every case of venereal ulcer until sufficient time has elapsed to allow the syphilitic characteristics to appear, A dark field examination should be made and in all doubtful cases the Wassermann test should be applied. Phimosis. — Phimosis is a stenosis of the preputial orifice preventing retraction of the foreskin. This is generally a congenital affection, but may result from cicatricial narrowing, from the healing of a venereal ulcer, or as a result of trauma. In children there may be adhesions between the glans and prepuce, and a collection of smegma just behind the corona from the retained secretions of the coronal glands. The condition, as a rule, produces no symptoms, but occa- sionally there is itching or sense of discomfort in the parts, and not infrequently a balanitis is present. In highly nervous individuals the condition may give rise to a more or less constant sexual irritation, evidenced by frequent erections, erotic dreams, and seminal emissions. In younger children, nocturnal incontinence of urine may occur. Treatment. — In infants the prepuce usually can be stretched suffi- ciently to allow the glans to be uncovered. If this is impossible, or if, after retraction, too much constriction exists, a simple dorsal incision is generally all that will be required unless the foreskin is abnormally redundant. In older children and adults, and in infants with an excessive length of prepuce, circumcision is to be advised. Two satisfactory methods of circumcision are as follows: Either general or local anesthesia may be employed ; the former is generally to be preferred in young children. (1) After careful disinfection of the parts the foreskin is drawn gently and evenly downward, and that part projecting beyond the apex of the glans cut off obliquely from above, downward and outward to enlarge the opening (Fig. 324). The skin retracts and the mucous layer of the prepuce is exposed. This layer is slit dorsally as far as the coronal sulcus and the redundancy is removed with scissors. The bleeding points, usually a dorsal, two lateral, and a f renal, are secured if necessary. The parts retracted and united with catgut sutures, after which a dressing of sterile gauze is applied, (2) The preputial orifice is tensed upon the glans. Three clamps, two dorsal and one median ventral, are applied. The prepuce is slit between the two dorsal clamps with scissors or upon a grooved director as far IS FLA MMATOh'Y DISEASES 693 as the coronal sulcus. The two flaps outlined between this slit and the frenum are removed by trimming close to the coronal sulcus, care being taken to leave a narrow ledge of mucous membrane for suture. Fig. 324. — Circumcision. Paraphimosis. — This condition, which is fairly common, results from forcibly retracting an abnormally narrow prepuce. The con- stricted part, after it is drawn backward behind the corona, exerts pressure on the veins and causes the glans and adjacent tissues to swell and become markedly edematous. In extreme cases considerable sloughing may occur. An edematous collar of mucous membrane Fi<;. 325. — Reduction of paraphimosis. (Phillips.) is usually seen just behind the corona and above this a sulcus indicating the position of the constricting band. Sometimes a second edematous collar and sulcus may be observed. The condition is a painful one, 692 DISEASES OF THE PENIS AND SCROTUM and if neglected, reduction by the ordinary non-operative means becomes impossible. In the early stages the penis should be thoroughly lubricated, surrounded with hot gauze compresses, and the parts gently but firmly squeezed with the hand to drive the blood out of the glans and to reduce its size. The edematous prepuce is then drawn forward with the thumb and index finger of one hand, while the glans is pressed backward, as shown in Fig. 325. When reduction cannot be effected by this plan, an anesthetic should be administered, the constricting band freely divided, and a more or less typical circumcision performed. TUMORS OF THE PENIS AND SCROTUM. Papilloma. — Papillomata, or warts, are exceedingly common on the glans and prepuce. They are usually found in the coronal sulcus and on either side of the frenum. They appear also on the scrotum. When in the region of the glans penis, they are usually associated with phi- mosis or other conditions producing irritation and an excessive amount of moisture of the parts, especially balanitis and gonorrhea. They are to be distinguished especially from syphilitic condyloma and epithelioma. In case of doubt a microscopic examination of the tissue should be made. Papillomata are not common in elderly individuals. Wart horns are occasionally observed in this region. Sebaceous cysts, dermoids, lipomata, and other innocent growths have been observed in the scrotum. Epithelioma. — Epithelioma occurs both on the penis and scrotum; most commonly on the glans, where it frequently develops from a papilloma, more rarely from a chronic ulcer. In the former case the growth may resemble at first a papilloma; later the surrounding tissues become infiltrated, and ulceration occurs. If the growth becomes infected its original papillomatous character is often obscured. When developing from an ulcer there may be no papillomatous growth, but a progressively infiltrating ulcer, which later may extend to the scrotum. The growth may be concealed under a tight phimosis and is often accompanied by a serous, purulent or fetid discharge. The inguinal lymph nodes are involved early in the disease. Cancer of the penis seems to be less malignant than in any other parts of the genito-urinary system, and in a considerable number of instances cures have followed radical removal. In fact, Legueu reports the case of an elderly patient with extensive epithelioma where he removed the penis and scrotum, but left enlarged inguinal lymph nodes owing to his feeble condition. He remained well and without recurrence for four years. The enlarged inguinal nodes gradually diminished in size. Sarcoma. — Sarcoma of the penis is rare, and from the 18 reported cases is much more malignant than carcinoma. Endothelioma has been reported in a few instances. TUMORS OF THE PENIS AND SCROTUM 693 Epithelioma of the Scrotum.— Epithelioma of the scrotum, or chimney-sweep's cancer, is apparently more frequently observed in England than elsewhere. It begins by what is described as a "soot- wart," which may occur on any part of the scrotum, more commonly on the lower and front part, and for a long time remains as an apparently innocent papilloma. Later, ulceration occurs, which gradually spreads and is accompanied by enlarged lymph nodes in the groin, which in turn break down, leaving extensive ulcerated areas often exposing the iliac vessels. The lesion in the lymph nodes is often inflammatory; true metastases are late to develop as a rule. Rarely the primary growth may remain small, while the inguinal metastases assume a large size, giving rise to the belief that the primary growth occurred in that region. The testicles not infrequently become invaded and the crura of the penis may be involved. Treatment. — Papillomata of the penis often disappear sponta- neously when the conditions which favor their production are removed. Hence circumcision and treatment addressed to chronic urethral discharges may be indicated. Excision of the individual tumors with the knife, scissors, or snare is to be preferred to treatment by caustics. In cases, however, which present an extensive base, the entire area may be curetted off and the removal site cauterized. Recurrences are common. The treatment of other innocent growths in this region is the same as in other parts of the body. Epithelioma of the penis should be treated by amputation of the organ and removal of the inguinal lymph nodes. In the early stage of the disease, when the growth is limited to the glans, the amputation can be made about the middle of the organ. Considerable hemorrhage may follow division of the corpora caver- nosa, which is best controlled by buried sutures. The skin is then united to the urethra by a few absorbable sutures. In more advanced cases total amputation should be performed. In this operation the corpora cavernosa should be completely removed, the crura being cut close to the pubic arch, the entire chain of lymph nodes and surrounding areolar tissue in both inguinal regions dissected out, and the urethra sutured in the perineum. It is occasionally necessary to sacrifice both testicles and the scrotum. Free excision of soot-warts is to be advised as soon as they appear, for at first, they are frequently innocent and show no tendency to recur after removal. Later the scrotum should be protected by proper clothing. When the disease assumes a malignant character it should be extensively removed, sacrificing the testicles if necessary, and removing all the areolar tissue and lymphatics of both inguinal regions. The inguinal lymph nodes should be removed with the growth, as metastases have been known to develop years after the excision of the primary tumors. Varicocele. — Varicocele is a varicose or dilated condition of the veins of the spermatic cord. It may be symptomatic resulting from G94 DISEASES OF THE PEXIS AXD SCROTUM abnormal intra-abdominal pressure and is not infrequently -ecu accompanying new growths of the kidney, and in all cases of rapidly developing left sided varicocele, the kidney should first be excluded as a possible causative factor. Idiopathic varicocele developing without demonstrable cause is of frequent occurrence, being present to some degree in about 10 per cent, of all adult males (Keyes). In the vast majority of cases it occurs on the left side, for the reason that the venous blood-pressure is greatest on this side owing to the greater length of the left spermatic vein and its rectangular implantation into the renal vein. It will be remembered that as the spermatic cord emerges at the external abdomi- nal ring the spermatic veins divide into a large number of trunks, some of which adhere closely to the vas deferens and its artery, while others are more or less separated from the vas by loose areolar tissue. In a condition of varicocele all of these branches become dilated, elongated, and their walls thickened and often thrombosed. The disease is expecially apt to involve the larger anterior group of veins which accompany the spermatic artery. This produces an increased weight for the dartos to support, and as it gradually yields, the left half of the scrotimi with its mass of veins and testicle sags lower and lower until it hangs from one to three inches below its fellow. The condition pre- sents no serious complications or sequelae although it is occasionally followed by atrophy of the testicle. Symptoms. — The symptoms of varicocele are of two kinds, the local and the nervous. Local symptoms may be entirely absent, and the condition may be discovered by accident by the patient, or his atten- tion may first be directed toward it by his medical adviser. When large, the varicocele may cause a sense of weight and sometimes dragging pain in the scrotum and groin, which are relieved on lying down and increased by severe bodily strain. Atrophy of the testicle occasionally occurs. The nervous symptoms are varied in character but correspond to the group usually present in sexual neurasthenia. Sexual weakness, premature ejaculation, and erotic fancies are the chief complaints. Diagnosis. — The diagnosis of varicocele is not difficult. Enlarge- ment of one-half of the scrotum and the presence of the dilated veins, which give to the examining hand the sensation of a mass of earth worms, are pathognomonic of the condition. The veins are emptied when the patient assumes the recumbent posture, but quickly refill when the erect position is again taken. Pressure over the inguinal ring applied while the patient is on his back and maintained after h > rises, will retard but not prevent refilling of the veins, unless the pressure is such as to occlude the arteries. Treatment. — In mild cases without symptoms no treatment is re- quired. If there is a certain amount of pain or dragging sensation, the wearing of a suspensory bandage will often give prompt relief. In the severer cases, in which the symptoms are progressive or are of TUMORS OF THE PENIS AND SCROTUM 695 sufficient moment to justify the use of more radical measures, opera- tion is advisable, which may be performed in the following maimer: After the usual preparation of the patient, ether is administered and an incision one inch in length is made oxer the spermatic cord as it emerges from the external abdominal ring. Through this incision about two inches of the cord are withdrawn, drawing the testicle to the upper part of the scrotal pouch. The various tunics are then carefully divided until the large mass of dilated veins is reached. These are easily separated from the small mass which surrounds the vas deferens, which should not be disturbed. The large mass is drawm outward, freely separated from the rest of the cord, and double ligated with chromicized catgut, one ligature being placed near the external ring and the other just above their junction with the tissues of the epididymis. . After the ligatures are applied the intervening mass is cut away, the two stumps approximated by tying the ends of the upper and lower ligatures. The cut surfaces are then sutured together and the wound closed without drainage. Many surgeons make the incision through the tissues of the scrotum. There is no advantage in this, and the writer believes there is more risk of infection on account of the corrugated skin and difficulty in keeping the dressings snugly applied. Operation is not infrequently followed by a more or less extensive fibrosis of the testicle. A temporary enlargement of the organ is usually noted for a few days after operation. Hydrocele. — Hydrocele is a collection of fluid in the tunica vaginalis testis. This may be due to an acute inflammation of the epididymis (acute hydrocele), to a chronic inflammatory process of the tunica, to trauma, and to other conditions the nature of which is not well understood. Acute hydrocele almost always accompanies inflamma- tions of the testicle or epididymis, and is sometimes observed as a com- plication of the acute infectious diseases. It is characterized by its sudden onset and the development of a tense painful swelling in the scrotum. It is usually accompanied by dragging pain and the symptoms of the condition which it complicates. It may be con- founded with strangulated hernia in children. The fluid is usually scanty, and tends to disappear spontaneously but paracentesis is sometimes indicated to relieve pain. If suppuration occurs which is rare, the tunica vaginalis must be incised and treated as an abscess cavity. Chronic hydrocele is most frequently observed in middle and old age. It affects both sides with equal frequency and is sometimes double Fig. 326. It is predisposed to by conditions tending to produce chronic stasis and its onset is not infrequently determined by some previous inflam- matory condition. Trauma appears to be a factor in some instances. In cases of rapid development the tunica vaginalis is distended and thin, but in those of long standing there may be a good deal of chronic inflammatory thickening. The condition is aggravated by recurrent injuries and frequent tapping. The hydrocele sac is usually pyri- 696 DISEASES OF THE PENIS AND SCROTUM form in shape partially surrounding the testicle and epididymis which are to be found behind and below it. The amount of fluid varies Fig. 326.— Double hydrocele. Fig. 327.— Hydrocele. TUMORS OF THE PENIS AND SCROTUM 697 from a few ounces to accumulations of enormous size. It is usually pale yellow with a specific gravity of 1022 to 1026 and presents the laboratory features of any chronic exudate. The tumor may produce a certain degree of mechanical discomfort depending upon its weight and size. It usually develops without other symptoms. Tumors of large size may draw down the skin of the pubic region, completely bury- ing the penis between its folds. The swelling is at first oval but soon becomes pear-shaped (Fig. 327). It presents a smooth, tense surface and is covered by normal freely movable skin. Its consistency is elastic; fluctuation and sometimes a fluid wave may be elicited. The tumor is found to be translucent on transillumination unless the contents are unusually opaque as is sometimes the case with chylous fluids. The diagnosis may be established by the introduction of a needle and the withdrawal of a straw-colored fluid, not spontaneously coagulable containing albumin and cholesterin crystals. Hydrocele of the cord is a circumscribed collection of fluid in some unobiliterated portion of the funicular process along the cord. One or more small oval elastic tumors may be seen over the region of the spermatic cord. It sometimes happens that two hydrocele cavities may be connected by a narrow passage, the so-called bilocular hydro- celes. Double hydrocele (Fig. 326) is rare. Congenital hydrocele is a collection of fluid in the unclosed funicular process of the peritoneum, and is generally associated with the presence of a congenital hernia. The characteristic sign of this form of hydro- cele is that it disappears when the child assumes the recumbent posture, but reappears when he stands erect. Chylous hydrocele is a distension of the tunica vaginalis w T ith a milky fluid resembling chyle. It is due to filariasis. Treatment. — The palliative treatment of hydrocele consists in tapping the cyst and withdrawing the fluid. To tap a hydrocele prop- erly the scrotum should be disinfected and rendered tense by grasping it firmly with the hand. A sterile trocar is then introduced through the anterior wall, the instrument being directed somewhat upward and backward to avoid wounding the testicle, care being taken to avoid bloodvessels. After the fluid is withdrawn the opening is closed with a bit of sterile cotton and collodion. The fluid slowly returns and the process has to be frequently repeated, usually in from three to six months, the intervals becoming shorter with each repetition of the procedure. The radical cure of hydrocele is effected by two methods, that by injection of pure carbolic acid into the sac, and the open operation. If the injection method is to be practised, the scrotum is prepared, in the usual manner, and the needle of a hypodermic syringe contain- ing 5 or 10 drops of pure carbolic acid is thrust into the upper part of the sac and held by an assistant. The surgeon then introduces a trocar below and withdraws the fluid. When the sac is emptied, the needle of the syringe still being within the sac, the carbolic acid is 69S DISEASES OF THE PENIS AND SCROTUM injected and evenly distributed by rubbing the walls together. Both openings are then sealed and the patient placed in bed. A certain amount of pain and swelling of the parts occurs during the succeeding forty-eight hours, but this quickly subsides. A cure by this method may be expected in about 90 per cent, of the cases. Several open operations are practised. The simplest one is to make an incision into the sac, evacuate the fluid, and apply pure carbolic acid to the interior by means of a cotton swab, after which the wound is partly united with sutures and a small gauze or rubber tissue drain left in the cavity for two or three days. Another method is to incise, evacuate the fluid, and pack the cavity with gauze. A third method and perhaps the surest of all, is to incise the sac freely and then dissect out its parietal layer, arrest bleeding, and partly close the wound, pro- viding drainage by a gauze packing or the introduction of a small folded piece of rubber tissue. Recently several surgeons have advised the following simple procedure, which seems to be satisfactory. After incision through the scrotum, exposing the tunica vaginalis, the latter is opened by a small longitudinal cut and the fluid allowed to escape. The testicle is then drawn outward through the opening in the tunica, which is thereby completely everted, leaving its serous surface in con- tact with the areolar tissue of the scrotum. The cutaneous wound is then closed without drainage. All of the open methods require a period of convalescence of from ten days to two weeks. CHAPTER XXV. INJURIES AND DISEASES OE THE TESTICLE, SEMINAL " VESICLE, AND PROSTATE. INJURIES AND DISEASES OF THE TESTICLE. Ectopic Testicle. — Imperfect descent of the testicle may result in its remaining in the. abdominal cavity, near the internal abdominal ring, in the inguinal canal, in or just without the external ring. Under the two last conditions the organ is usually movable, and often may be drawn upward or forced downward at will. In its normal descent the testicle may for some reason escape the scrotal pouch and lie in the subcutaneous tissues of the groin or perineum. Odiorne and Simmons, from a recent study of 77 cases, conclude that a retained testicle may develop normally until puberty, but if it is not then placed in the scrotum further development is arrested and the organ remains functionless. In its faulty position an unde- scended testicle may be the seat of frequent traumata, which give rise to inflammatory attacks and fibrous changes. Such testicles not infrequently are the seat of malignant disease later in life. Undescended testicle is often associated with congenital inguinal hernia. Treatment. — The treatment of this condition should, as a rule, be undertaken before puberty, preferably between five and ten years of age, when an attempt may be made to place the organ in the scrotum. In the inguinal, crural, and perineal varieties this is often possible. In the higher varieties of undescended testicle this is impossible, and the testicle should be allowed to remain in the abdominal cavity or be removed. The best operation for undescended testicle is that of Beven and should consist in an incision along the inguinal canal extending downward to the scrotum. The inguinal canal is opened as in the operation for hernia, and the upper portion of the spermatic cord carefully separated from the generally patent funicular process of the peritoneum down to the upper margin of the testicle. The peritoneal pouch is next ligated near the internal ring and divided, and the redundant portion above the tunica vaginalis removed, or, as is often necessary, the tunica reconstructed bv a plastic procedure. Traction is then made upon the cord to determine its length. If too short to allow the testicle to lie freely in the scrotum, the spermatic artery and veins may be ligated and cut. If this is not sufficient to allow the organ to lie easily in the scrotal pouch, the floor of the inguinal 700 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE canal should be divided and the cord transplanted to allow it to emerge from the abdomen near the pubic spine. This will give an increased length to the cord and allow an inch or more of descent. If the cord is still too short, it may be separated by the ringer from its intra-abdominal attachments. A pocket should next be made by separating the tissues of the scrotum, and the testicle and its envelop- ing tunics placed within it and held by one or two catgut purse-string sutures at the upper part of the scrotal sac. The inguinal canal should then be repaired as in the Bassini operation for hernia and the wound closed. Contusions of the Testicle. — Contusions of the testicle are of fre- quent occurrence and result from a variety of traumata. Symptoms.- — The symptoms are a severe, sickening pain accom- panied often by a grave degree of shock, evidenced by pallor, weak- ness, cold perspiration, and a rapid, feeble pulse. Treatment. — The treatment should consist in rest and hot fomenta- tions to the injured part. Severe contusions are occasionally followed by inflammation and subsequent atrophy of the organ. Wounds of the Testicle. — Wounds of the testicle give rise to much the same symptoms as severe contusions, and in these cases the surgical treatment should always be carried out under general anesthesia on account of the severe shock which frequently accompanies the handling and suturing of this highly sensitive organ. Wounds of the testicle should be promptly repaired, under the strictest aseptic precautions, for the reason that a failure of union and infection of the parts frequently give rise to hernia testis, a condi- tion characterized by protrusions of large masses of convoluted tubules, which form a soft, bleeding, fungating mass requiring castration. Torsion of the Spermatic Cord. — Torsion of the spermatic cord is a rare condition caused by a twisting of the cord and rotation of the testicle, the etiology of which is not well understood. A fairly large proportion of the cases are associated with imperfect descent of the testicle, and in a few instances persistence of the mesorchium has been noted. Rotation results in a cutting off of the blood supply, which gives rise to hemorrhagic infarction of the organ. In the milder varieties there is pain in the testicle of a sickening character, with nausea and evidences of shock. In the severe forms the vessels may be so strangulated as to give rise to gangrene of the organ. In these cases there is generally to be felt an indurated swelling at the seat of the twist, above the testicle, which is tender to the touch. If the condition cannot be relieved by manipulation, open operation is to be advised with a view to reducing the displacement or removing the gangrenous testicle. Acute Epididymitis. — Acute epididymitis is an inflammation of the epididymis, caused in the great majority of cases by extension of a gonorrheal process from the urethra. This complication is practically always preceded by the occurrence of a posterior urethritis, and the INJURIES AXD DISEASES OF THE TESTICLE 701 process may extend from the posterior urethra along the ejaculate in- ducts and vasa deferentia, or by the lymphatics to the epididymis. It may occur at any period in the disease, but is rare before the second week. The disease also may arise from infection occasioned by the passage of unclean urethral instruments, or from an acute inflamma- tory focus in the prostate or seminal vesicle. Symptoms. — The symptoms are pain and tenderness in the region of the testicle, and the rapid formation of an indurated mass occupy- ing the position of the epididymis and partly surrounding the testicle, which, as a rule, is not involved in the process. The swelling may reach the size of a small orange, is accompanied by redness and edema of the scrotum, and is exquisitely tender. A certain amount of fluid frequently is present in the cavity of the tunica vaginalis. In certain instances pain and tenderness in the groin over the region of the spermatic cord precede the development of symptoms in the scrotum. In these cases the vas deferens can be felt as a thick- ened tender cord at or just below the external abdominal ring. The symptoms develop quickly, the scrotal tumor often doubling in size in twenty-four hours. There are fever, headache, malaise, and occa- sionally chills at the outset. Xot infrequently there is marked diminu- tion of the urethral discharge. These symptoms continue without abatement for several days; the pain and tenderness then gradually subside and the swelling slowly disappears. A small hard nodule often persists in the head or tail of the epididymis for months or years, which may completely occlude the lumen of the vas, and, if double, give rise to sterility. Double epididymitis, however, is comparatively rare. Treatment. — As in other acute and painful inflammatory processes, it is desirable at the outset to empty the bowels and insure absolute rest for the part. Calomel and salts, followed by rest in bed, are therefore to be advised in the beginning of the attack. Elevation of the scrotum by means of a folded towel or a broad strip of adhesive plaster placed beneath the scrotum and extending from one thigh to the other will often relieve the dragging pain, and the application of heat by means of fomentations or flax-seed poultices, will afford additional comfort. In certain cases where the pain is severe and not relieved by these measures, aspiration of the fluid in the cavity of the tunica vaginalis (acute hydrocele) will give relief. In more severe cases Hagner has recommended freely opening the cavity of the tunica vaginalis and making multiple punctures through the fibrous sheath of the inflamed epididymis. For obvious reasons, treatment by rest in bed is impracticable in many cases. In these the application of 10 per cent, guaiacol ointment and the use of a suspensory bandage will be found beneficial. When the pain is acute and not relieved by the ordinary means, lightly touching the surface of the scrotum with the white-hot cautery point, as recommended by Halsted, will occasionally relieve the pain and 702 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE enable a previously bedridden patient to be up and about. The use of the dry poultice was recommended by the writer in 1891, especially for absorption of the indurations which frequently persist for a long period after the acute symptoms have passed. This dressing consists in a moderately thick layer of cotton applied over the inflamed half of the scrotum. This is covered by a layer of rubber protective tissue so fashioned that it completely encloses the diseased area, with its edges extending on to the healthy skin of the scrotum in a manner partly to overlap but not entirely enclose the healthy side. This is secured by a snugly applied gauze bandage, and the whole held in place by a suspensory. This dressing, by retaining heat and preventing absorption of the moisture abundantly supplied by the sweat-glands, possesses all the advantages of a flax-seed poultice, and in addition, exerts moderate compression, insures suspension, and allows the patient to be up and about. Inunctions of mercurial ointment and strapping the testicle are occasionally employed to promote absorption of the exudate in chronic cases. For the sterility caused by the presence of indurated masses in the globus minor of the epididymis Martin recommends epididymo- vasostomy, or anastamosing the vas deferens into one of the tubules of the globus major. Both Martin and Hagner have reported success- ful cases in which repeated examinations had failed to find motile spermatozoa in the seminal fluid before operation,\vhile after operation they are present in large numbers. In several instances also a pregnancy has followed. Orchitis. — Orchitis is an inflammation of the testicle, caused gener- ally by trauma, occasionally by septic infection of the deep urethra, or metastases from mumps or other infectious diseases. In these cases the inflammatory process is limited to the tissues of the testicle proper, the epididymis not being involved. The term orcho-epididymitis is applied to those inflammations which involve both the testicle and epididymis. Symptoms. — The symptoms are pain of a severe and often 'of a sickening character, extending from the scrotum to the groin and back, swelling, and great tenderness of the organ. If the swelling can be palpated carefully, it will be found to be globular in shape rather than semilunar, as in the case of epididymitis. Accompanying the local symptoms there are fever, general weak- ness, and often nausea and vomiting. If the disease is due to infection with pyogenic organisms, the process may go on to suppurat on. In the majority of instances, however, resolution takes place, followed in many cases by atrophy of the organ. Treatment. — The treatment is the same as for epididymitis. Syphilitic Testicle.— Syphilis may affect either the epididymis or the testicle. Syphilitic epididymitis is rare; it occurs in the secondary or tertiary stage, and begins usually in the globus major, differing thereby from the gonorrheal and tuberculous affections, which usually INJURIES AND DISEASES OF THE TESTICLE 703 have their origin in the globus minor. The disease spreads to the other portions of the epididymis, and may be accompanied by an effusion of serum into the tunica vaginalis. It is often bilateral. As a rule, there is little or no pain, and the organ is not sensitive to press- ure. In syphilitic orchitis, which is a more common affection, the disease generally occurs in the late secondary or tertiary stage. It may be diffuse or circumscribed. In the diffuse variety there is an oxer- growth of the connective-tissue framework and fibrous tunic, giving rise to a symmetric enlargement of the gland. In the circumscribed variety there is a gummatous infiltration of a part only of the gland, forming an irregular enlargement or globular tumor. The former variety causes a painless enlargement which may persist for years (syphilitic sarcocele), or finally disappear and cause atrophy of the organ; the latter, or .gummatous variety if untreated may break down and suppurate. Diagnosis. — Gonorrheal epididymitis is easily distinguished from the syphilitic variety by the rapidity of the process, the occurrence of acute pain, and the size of the enlargement. The differential diagnosis between tuberculous and syphilitic epididymitis is more difficult. In the tuberculous affection the process generally begins in the tail of the epididymis; it progresses more slowly than the syphilitic form, it practically always invades the vas deferens, often the seminal vesicle and prostate. The disease frequently follows the gonorrheal variety. The testicle itself is rarely involved except secondarily. In syphilitic epididymitis the globus major is usually the part first affected. When the entire epididymis is involved, there is nothing in the feeling of the mass to distinguish it from either the tuberculous or chronic gonorrheal form of the disease. The chief characteristics, however, are that the growth is practically painless, is comparatively insensitive to pressure, and that it never involves the cord, seminal vesicle or prostate. Syphil- itic orchitis is far more common than syphilitic epididymitis. It presents itself as a painless circumscribed or diffuse swelling of the organ, which is prone to gummatous degeneration, softening, and abscess-formation. A positive Wassermann reaction may help in diagnosis in an otherwise obscure condition. Treatment. — Early syphilitic epididymitis requires no treatment other than that addressed to the constitutional condition. In the later affections, potassium iodide should be given in large doses, also mercury in the form of inunction or vapor baths, and locally by means of the constant application of mercurial ointment to the diseased testicle. In all forms except the chronic fibrous interstitial orchitis the prognosis under intelligent treatment is favorable. Tuberculosis of the Testicle. — This disease occurs as a chronic, slowly progressing induration and enlargement of the epididymis. In the majority of instances the globus minor is the part first affected, and early appearance of the disease in this locality may differ in no respect 704 DISEASES OF TESTICLE, SEMI SAL VESICLE, PROSTATE from the chronic enlargements sometimes persisting after a gonorrheal epididymitis. In fact, tuberculosis is frequently engrafted upon such a focus. As the disease spreads it next involves the cord, then the remaining portions of the epididymis, the seminal vesicle, and prostate, and finally it invades the testicle proper. If the resistance of the individual is considerable and he lives amid favorable hygienic sur- roundings, the progress is often exceedingly slow, and the primary nodule may remain stationary for months or years. Under less favorable conditions the process may extend rapidly and be associated with evidences of tuberculosis in other organs. In these cases the tuberculous nodules soften early, become adherent to the tissues of the scrotum, and eventually rupture and discharge, leaving one or more sinuses, and occasionally a hernia testis. Diagnosis. — In the early stages of a tuberculous epididymitis there may be no symptoms other than the presence of a small area of indura- tion in the epididymis. In other cases there are localized pain and discomfort, and a dragging sensation. Tenderness may exist, and occa- sionally is well marked. When the entire epididymis is involved, it can be felt as a dense nodular semilunar mass moulded over the posterior border of the testicle, and separated from it by a distinct sul- cus. The cord generally can be felt to be thickened and nodular, somewhat suggesting the feeling of a string of beads. When the process involves the testicle, this organ enlarges, and later presents on its surface areas of softening which may suppurate and discharge a curdy pus. For a differential diagnosis between gonorrheal, tuberculous, and syphilitic disease of the testicle, see page 703. Treatment. — In the earlier stages these cases are frequently much benefited by a change of air. Living in a mountainous district, espe- cially if surrounded by pines, will often arrest the progress of the disease. When this is impracticable, cod-liver oil, iron, arsenic, and a highly nutritious diet will often prove of benefit. The early removal by surgical means of a localized tuberculous focus when limited to the epididymis or testicle is, however, the best treatment, and should be advised whenever the disease is thus limited. Undoubtedly castration is the safest and surest means of removing such a focus. The propriety of removing a diseased epididymis only, in a case in which there is no involvement either of the cord or of the testicle, has been largely discussed of late by the profession ; and while such a procedure might be advisable under such conditions, the oppor- tunities for carrying out this plan are exceedingly rare, for in the majority of instances when the parts are exposed the disease is found to involve the mediastinum testis or the visceral layer of the tunica vaginalis. If the cord is extensively involved, and especially if there is evidence of disease of the seminal vesicle, all of these structures should be removed. TUMORS OF THE TESTICLE 705 Removal of a painful and disorganized testicle in the presence of extensive tuberculous disease elsewhere occasionally may be justifiable for the relief of suffering. TUMORS OF THE TESTICLE. While the subject of tumors of the testicle has been surrounded by much confusion, recent investigations have led to the belief that most of the solid tumors occurring in the testicle arise from embryonic rests which may be of exceedingly complex structure. Thus we have the slow-growing teratomata, which are composed of fibrous tissue, glandular and muscular elements, cartilage, myxoma- tous material, etc., the so-called mixed tumors of the testicle. These, as a rule, are innocent growths, may reach a certain size, and then remain stationary for years. At a later period, however, these tumors may take on a malignant character, grow rapidly, develop metastases, produce cachexia and death. Carcinoma of the testicle occurs in both the alveolar type and the diffuse, rapidly growing cellular variety. Sarcoma is, perhaps, more frequently encountered than carcinoma. It occurs in the slow-growing, hard, fibrous variety, or as a diffuse, rapidly growing, cellular tumor, which closely resembles the soft, cellular carcinomatous growth. Ewing, who has given much attention to these tumors, is of the opinion that most of them arise from embryonal rests made up of the various tissues found in the innocent teratomata, but that a lawless proliferation occurs in one of the many tissues present, which may grow rapidly and obscure the other elements of the original focus. This view was suggested by the finding of a small focus of complex teratomatous elements in a tumor which, in other respects, presented the gross and histologic picture of a diffuse cellular carcinoma; and also by the fact that, in malignant degeneration of a teratoma, one occasionally can find both carcinomatous and sarcomatous areas, with evidence of metastasis, both by the bloodvessels and lymphatics. In a few recorded cases more or less typical chorion epithelioma has been reported in a testicular tumor. A class of tumors has been described by Bland-Sutton and others as arising from the paradidymis. They may appear as single cysts, generally small, occurring near the globus major of the epididymis, and often containing a milky fluid (spermatoceles), or as larger masses made up of numerous communicating cysts, sometimes with intracystic growths. These tumors may reach a large size and may compress the testicle. They are commonly spoken of as adenomata or as fibrocystic disease of the testicle, and, as a rule, are innocent. Diagnosis. — Subjective symptoms are not marked in tumors of the testicle. Pain is rarely present except in the later stages of the more malignant growths. The presence of an enlargement of the organ and a sense of weight and dragging are all that is complained of by the 45 706 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE patient. The cellular carcinomata and sarcomata are, as a rule, easily recognized by their rapid growth and soft or elastic consistence; the fibrosarcomata, by their slow growth, their hardness, and the smooth, regular outline of their surface; the mixed tumors, by their irregular outlines and uneven consistence; the cysts by their oval shape and their elasticity. In many cases the diagnosis cannot be made clinically. Prognosis. — In malignant disease of the testicle the prognosis is generally unfavorable, chiefly for the reason that the growth does not give rise, in its early development, to painful symptoms. In the carcinomata and, to a certain extent, in the sarcomata, lymph- node metastasis takes place early and in an inaccessible position; for Most has shown that the lymphatics from the testicle pass upward with the spermatic vessels and enter nodes surrounding the aorta and vena cava just below the renal vessels. In this locality they are covered by the peritoneum and root of the mesentery, making their surgical removal impracticable. Legueu has recently reported a series of 100 cases of malignant disease of the testicle with 19 cured after three years. Treatment. — With the exception of the small cysts which appear in the neighborhood of the head of the epididymis, all tumors of the testicle should be removed at the earliest possible moment, for the reason that the majority are genuinely malignant and nearly all have a potential malignancy. Castration with removal of all affected portions of the scrotum and adjacent lymphatics is the operation of choice. DISEASES OF THE SEMINAL VESICLE. Seminal Vesiculitis. — Seminal vesiculitis is an inflammation of the seminal vesicle and ampulla of the vas deferens, caused in the majority of instances by the extension upward of a gonorrheal infection of the urethra through the ejaculatory duct. Other infections of the seminal vesicles are occasionally observed. In these cases the inflammation is generally preceded by a condition of atony of the muscular walls, giving rise to retention of the secretions. This is usually the result of sexual excesses, especially in early life. Symptoms. — The symptoms of an acute seminal vesiculitis are often obscure. There may be pain deeply seated in the perineum or rectum, bladder irritability, and sexual disturbances, evidenced by frequent erections and painful ejaculations. In other cases subjective symp- toms are absent, and the diagnosis can only be made by feeling on rectal examination a soft, boggy, elongated, tender body in the posi- tion of the vesicle. Occasionally in mixed infections an abscess may develop in and about the vesicle, giving rise to severe throbbing pain, fever, chills, and marked tenderness on palpation. Unless relieved surgically, the abscess will generally rupture into the rectum, exception- ally into the bladder, very rarely in both directions, causing a vesico- rectal fistula, a condition giving rise to great suffering, and presenting DISEASES OF THE SEMINAL VESICLE 707 for its successful treatment an extremely difficult surgical problem. Iu chronic vesiculitis the symptoms are often only those of sexual neurasthenia, although in the majority of instances there are lumbar pains, rectal discomfort, and often an irritable bladder from an exten- sion of the process to the trigone. The condition is important, how- ever, on account of the frequent reinfections of the urethra which occur during its progress. Fuller, who was the first to study this condition carefully and to appreciate its clinical importance, has de- monstrated that many neglected and supposed incurable cases of chronic urethritis may be cured by relief of the vesicular disease. This author has also called attention to the fact that a chronic vesiculitis is perhaps the most important etiologic factor in chronic arthritis, not only of the gonorrheal type but also other varieties; and Billings has expressed the belief that many cases of arthritis deformans are due to a chronic infection of the vesicles by the streptococcus. Ureteral stricture and occlusion occasionally result from an exten- sion of the disease to the lower portion of the ureter. The author, on one occasion, encountered such a condition in which calcification of the inflammatory exudate gave an .r-ray shadow resembling a ureteral calculus. Division of the ureter above the stricture and vesical implantation, however, brought about a cure. Treatment. — In the acute stages the pain and perineal discomfort often may be relieved by hot rectal irrigations; gently stripping the vesicle with the finger in the rectum, and emptying it of its contents at regular intervals and treatment addressed to the urethral infection will generally bring about a cure. In the extremely chronic cases which resist this simple treatment, Fuller recommends exposure of the vesicle, with incision and drainage. By this operation he has suc- ceeded not only in relieving the local symptoms, but on several occa- sions has been able to rid his patient of a chronic sepsis, evidenced by obstinate and recurring gonorrheal arthritis and other symptoms of chronic toxemia. Tuberculosis of the Seminal Vesicle. — The seminal vesicle is occa- sionally the seat of a primary tuberculous focus, the infection reaching the part by the blood current. It may also occur secondarily from extension upward of a tuberculous infection from the testicle, or extension backward of an infection from the prostatic urethra. Symptoms. — In the earlier stages the process rarely gives rise to subjective sensations. At a later period there may be pain referred to the rectum or neck of the bladder, with frequency of micturition, vesical tenesmus, and sexual disturbances. On examination by rectal palpation, the finger detects a firm circumscribed induration of the vesicle clearly contrasting with the soft, boggy feel of the organ when the seat of a gonorrheal infection. As in other parts of the genito-urinary tract, a latent tuberculous focus is often awakened into activity by the occurrence of a gonorrheal infection. 708 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE Treatment. — When the disease is clearly limited to the vesicle the treatment should be operative, and the disease radically removed. In other cases the treatment should be hygienic and supporting. DISEASES OF THE PROSTATE GLAND. Acute Prostatitis. — Acute prostatitis is an inflammation of the pros- tate gland, caused in the majority of instances by the backward exten- sion of a gonorrheal process from the urethra, or from an infection con- veyed to the organ by the use of urethral instruments. The process varies in intensity from the slight transitory congestion and swelling of the gland which frequently accompanies a posterior urethritis, to an acute suppurative process which may destroy its entire structure. The infection reaches the prostate by direct extension of the inflammatory process from the urethral mucous membrane to the prostatic glands, large numbers of which open upon the floor of the canal. The mucous membrane lining the ducts of these glands becomes thickened, often occluding their orifices and retaining the infected secretions. This gives rise to a perifollicular inflammation, which may cause numerous indu- rated areas to appear throughout the gland, with more or less congestion and enlargement of the organ. One or more of these may suppurate and discharge into the urethra, or resolution may take place without sup- puration. This condition is described as follicular prostatitis. In severer cases these perifollicular indurations may extend rapidly and eventually involve the entire structure of the gland, which becomes greatly enlarged, hot, and tender. One or more foci of suppuration may appear, which usually coalesce, forming a single large abscess cavity. To this condition the terms diffuse or suppurative prostatitis have been applied. Diagnosis. — In the acute form of the disease the process is preceded by symptoms of a posterior urethritis: frequent and painful micturi- tion, vesical tenesmus, and pyuria. To these symptoms there are added a slight elevation of temperature and constant pain in the rectum and perineum. In severer cases there may be chills, high fever, and retention of urine from pressure of the swollen gland. Rectal examination is always necessary to establish the diagnosis, as all of the preceding symptoms may be present under other conditions. In the acute follicular variety of the disease the examining finger will feel the prostate somewhat swollen and tender, and studded with several small oval areas of induration. In the diffuse form the gland is symmetric- ally enlarged, sometimes to the size of a large orange, almost completely filling the pelvic cavity. It is hot, indurated, pulsating, and exceed- ingly tender. In the acute congestions which sometimes accompany a posterior urethritis there is also considerable swelling, but less tenderness on pressure, and the gland feels elastic rather than densely indurated. DISEASES OF THE PROSTATE GLAND 709 When suppuration occurs there is often retention of urine. There may be chills, throbbing pain, and increased fever; but these are not constant, as large abscesses are not infrequently encountered in individuals without fever or other constitutional evidences of sup- puration. There is generally, however, a marked leukocytosis. Fluc- tuation occasionally may be detected by rectal palpation. In some cases in which the abscess is small its seat often can be located by feeling an area of increased tenderness, and induration in some part of the gland. In untreated cases, rupture of the abscess generally takes place into the urethra, either spontaneously or as a result of the passage of an instrument for relief of the retention, and in the majority of instances is followed by recovery. Rupture into the rectum is less frequent, and recovery is slower and less certain. Rupture into the ischiorectal fossa and eventually into the perineal region is exceedingly rare. If the abscess ruptures posteriorly, the pus may burrow exten- sively beneath the rectovesical fascia, giving rise to an extensive pelvic abscess and symptoms of grave sepsis. It occasionally happens that rupture takes place both into the urethra and rectum, creating a recto- urethral fistula, which occasions great suffering and is repaired with difficulty. The deep pelvic lymph nodes may very rarely suppurate as a result of infection carried to them from an abscess of the prostate gland. In these cases there are evidences of grave sepsis, which do not dis- appear after evacuation of the prostatic focus. A continued leukocy- tosis, indefinite pain and discomfort in the lower part of the abdomen and in the rectum, are the only symptoms. The abscess thus formed may eventually point toward the posterior rectal wall. Treatment. — In the early stages of the disease the patient should remain in bed and the bowels be freely moved by calomel and salines. Hot rectal irrigation by means of the Kemp tube should be practised every five or six hours, and suppositories of opium or morphine and belladonna administered if the vesical tenderness and pain are severe. In the follicular form of the disease measures should also be employed to allay the posterior urethritis, as deep injections of protargol or silver nitrate, and irrigations with mild solutions of potassium permanganate. In the majority of instances under this method of treatment resolution will occur and suppuration be avoided. Relief of pain and a lowering of the temperature do not, however, necessarily mean that suppura- tion has not taken place. ^Yhen these occur without diminution in the size of the'glandular swelling, and when there is a marked leukocytosis, an abscess is probably present, and should be sought for by an explora- tory operation and drained through the perineum. Alexander advises the performance of an external urethrotomy, introducing the finger into the posterior urethra and rupturing the abscess into the canal by digital pressure. The author's plan is to expose the prostate by a perineal incision, as in the operation for prostatectomy; locate the pus by an exploring needle, then incise, and drain with a soft-rubber 710 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE tube. It is occasionally necessary to open both lateral lobes in this maimer. Chronic Prostatitis. Chronic prostatitis is a condition frequently following the acute form of the disease, or occurring during the course of a protracted posterior urethral inflammation. In the first class there may be an open cavity resulting from the rupture of a large abscess, which fills up from time to time, causing subacute symptoms, and then ruptures and remains quiescent for a long period. The cavity may contain a v calculus, or its interior may be incrusted by phosphatic salts. In the follicular variety, which is usually gonor- rheal in origin, there may be infection of one or more follicles, which are not occluded, but which furnish a secretion constantly reinfecting the urethral mucous membrane. Symptoms. — The symptoms of this condition are extremely variable. Pain, frequency in micturition, vesical and rectal tenesmus, may be present; also an obstinate gleet, with tripper faden and free pus in the urine. Bacteriuria may be the only symptom in some cases. Treatment. — The treatment of chronic prostatitis consists in meas- ures to relieve the chronic urethral inflammation upon which it depends, as irrigations, deep instillations of silver nitrate or protargol, together with general and sexual hygiene. Regular massage of the prostate is to be recommended in cases of chronic follicular prostatitis in addition to the above measures. Tuberculosis of the Prostate. — Tuberculosis of the prostate may occur as a primary disease, but generally is associated with tuberculosis of the testicles, seminal vesicles, or bladder. Symptoms. — The symptoms are those of prostatic and bladder irri- tation, generally progressive in character, and not dependent upon previous urethral disease. Treatment. — The treatment is unsatisfactory, as palliative meas- ures only can be adopted in the majority of instances. If, however, it can be demonstrated that a primary focus exists in the prostate, prostatectomy is indicated. Prostatic Calculi. — Calculi occasionally develop in the crypts of the prostate gland, and are caused by calcification of the corpora amylacea. They are small oval bodies of a light yellow or brown color, and are generally highly polished. Their presence in the prostate may cause no disturbance. If the cavities which contain them become infected, suppuration may occur, giving rise to symptoms of acute prostatitis. They are occasionally discharged by way of the urethra or may become lodged behind a stricture and give rise to retention. They should be removed surgically. Senile Hypertrophy of the Prostate. — Enlargement of the prostate gland occurs in about one-third of all men after fifty. In a small number of these the enlargement is of such a character as to interfere with the function of urination. The causes of prostatic overgrowth DISEASES OF THE PROSTATE GLAND 711 are not well understood, but it is probable that the chronic congestion which accompanies sexual abuses in early life and the inflammatory changes which occur in the gland as a result of early gonorrheal infection play some part in its production. Any or all of the anatomic structures which enter into the for- mation of the organ may partake in the process; thus we may have a general hypertrophy of the fibrous and muscular framework of the gland giving rise to a symmetric enlargement of the organ, or a local- ized hypertrophy of these structures, resulting in a unilateral enlarge- ment or outgrowth. Distinctly circumscribed tumors are present in more than half the cases, which may be made up of the glandular ele- ments (pure adenomata), or of the muscular and fibrous structures (fibromyomata), similar to those observed in the uterus. Symmetric enlargements produce, as a rule, less interference with urination than unilateral hypertrophies or irregular outgrowths. One of the commonest locations of the affection is in that portion of the gland lying between the ejaculatory ducts and base of the bladder, which when enlarged creates the so-called third lobe, which not infre- quently projects into the cavity of the bladder, elevates the urethral orifice, and sometimes acts as a ball valve, preventing the expulsion of urine, but in no way interfering with the passage of a catheter into the bladder. When the character of the enlargement is such as to cause obstruc- tion to the outward flow of urine, there occurs a compensatory hyper- trophy of the muscular walls of the bladder. The thickened muscular fibres are later separated by distension of the viseus, and a prolapse of the mucous membrane occurs between the separated fasciculi, giving rise to a condition described as a trabeculated bladder. If the urethral obstruction is progressive, the urine is expelled with more and more difficulty, a condition of atony gradually ensues, and a large amount of urine is habitually retained in the bladder which cannot be expelled by voluntary effort. The bladder then distends, often to an enor- mous size, the ureters dilate, and a condition of single or double hydronephrosis may result. In practically all cases of obstructive prostatic hypertrophy, infec- tion is at some time added by the passage of an instrument for pur- poses of diagnosis or treatment. If this occurs at an early period, before the obstruction is well marked, the resulting inflammatory process may be limited to the deep urethra or bladder. If the obstruc- tion is considerable and there is much residual urine, the infection generally spreads rapidly to the kidneys, giving rise to a septic pyelone- phritis which may prove fatal in a few days or weeks. Symptoms. — These occur very gradually, and rarely attract the attention of the patient until they have existed for some time. There is a slight frequency in urination, especially at night. With this there is often noticed a slight diminution in the force of the stream and some delay in starting the flow. 712 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE The symptoms gradually increase in severity. The calls to urinate are more frequent and urgent, there may be some pain at the close of the act, and there is a feeling of weight in the lower abdomen and perineum. Considerable variation exists in the severity of the symp- toms, due to the presence or absence of congestion of the prostate, which temporarily increases the obstruction and irritability. Attacks of temporary retention are of frequent occurrence and may cause great suffering. While the bladder remains free from infection the urine will be clear, and the patient may continue in excellent health, although his rest may be broken by frequent calls to urinate, and he may surfer considerable pain at each act of micturition. If, however, an unclean instrument is for any reason passed into the bladder, the entire clinical picture may suddenly change. Urination becomes much more fre- quent, extreme urgency and vesical tenesmus are added, fever appears, and the patient is prostrated. The urine becomes cloudy, alkaline in reaction, contains pus and often albumin and casts. Chills and sweats may occur; or the patient may gradually sink into a condition of uremia and general septic intoxication, ending fatally in from one to two weeks from the date of infection. If the infection is limited to the bladder or prostate, the symptoms of uremia and general sepsis may be absent, and those of acute prostatitis or cystitis may occur. In many of these cases which are not carefully observed, the diagnosis of malaria or typhoid fever is honestly made by those in attendance. Diagnosis. — This is established by examination of the gland by rectal palpation, by measuring the length of the urethra, and by ascertaining the presence of residual urine in the bladder. In the majority of cases of enlargement of the prostate, the examin- ing finger will easily detect it. The patient should be examined stand- ing with his trunk flexed at a right angle with his thighs, the hands rest- ing upon the seat of a chair or bench. Under normal conditions the forefinger introduced into the rectum easily reaches a point well above the posterior border of the prostate. It should be remembered that an enlargement of the so-called third lobe projecting into the bladder, capable of producing complete obstruction, may not be felt by rectal palpation. The urethral length can be measured by introducing a soft-rubber catheter and noting the distance from the meatus at which the urine begins to flow. The length of the normal urethra is about seven inches. In hypertrophy of the prostate it is generally increased. In some cases the distortion of the gland may be such as to cause the prostatic por- tion of the urethra to remain open, which would lead to error in estimat- ing the urethral length. The term residual urine refers to that portion left in the bladder after ordinary voluntary micturition. The amount is easily ascertained by the passage of a catheter immediately after urination and emptying the bladder by pressure above the pubis. In general it may be stated that the amount of residual urine habitually DISEASES OF THE PROSTATE GLAND 713 left in the bladder is a reliable index of the functional disturbance caused by the prostatic enlargement. The presence of any one of the three signs just mentioned, asso- ciated with a non-inflammatory irritability of the bladder in a man over fifty, would render the diagnosis of enlarged prostate probable; the occurrence of all three would render it certain. When the urethra easily permits the passage of an instrument cytoscopy will be of value, especially in the diagnosis of intravesical growths. Treatment. — Enlarged prostates which give rise only to slight vesical irritability without serious obstruction and without residual urine require no treatment. It is wiser also to avoid the introduction of instruments in aged subjects with moderate symptoms who presum- ably have a certain amount of residual urine, on account of the great danger of infection and its disastrous consequences in those of low vital resistance. In younger and more vigorous subjects, presenting symp- toms of prostatic hypertrophy, an examination should be made to determine the presence, and, if present, the amount of residual urine. Such examinations, however, should never be undertaken without explaining the dangers to the patient and without the employment of the strictest aseptic precautions, for it must be remembered that the first introduction of a catheter into the bladder of a subject with chronic obstructive disease of the prostate, and in the presence of any considerable amount of residual urine, is an operation the mortality of which is far greater than that following removal of the appendix. The patient should be placed in bed, the meatus and glans penis disinfected, and the anterior urethra irrigated with a solution of mer- curic chloride (1 to 10,000). The catheter should be freshly boiled, lubricated with sterile white vaseline or lubochondrine, and gently introduced by the surgeon after thorough preparation of his hands. 1 Just before the introduction of the catheter the patient should be instructed to empty the bladder as completely as possible. If more than an ounce of residual urine is found, the case is one requiring treatment. Two methods of treatment are open to the patient, the palliative and the radical. The former aims to relieve the painful symptoms by regular catheterism; the latter, to cure the disease by removing the obstruction. Catheterism is indicated in certain cases in which the amount of residual urine is comparatively small, in which the instrument can be used without undue force, in which it excites no reaction, and in old and enfeebled subjects whose condition is such as to contra-indicate operative procedures. The patient should devote at least a week to the process of begin- ning his catheter-life. He should remain in bed for two or three days, to avoid any possible exposure and to insure absolute rest. The catheter invariably should be introduced in the manner just indicated 1 It has been our custom at the Roosevelt Hospital for a number of years to insist upon freshly sterilized rubber gloves being used in every catheterization. 714 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE and with the precautions stated, the patient being particularly in- structed in regard to the care of his hands and the instrument. He should keep a number of catheters on hand, and should discard them as soon as they become brittle or in any way defective. If chronic cystitis exists, a daily irrigation with boric acid solution is to be advised. The soft-rubber velvet-eyed or coude catheter is the safest instru- ment to use, but the gum-elastic is often preferred by patients on account of its stiffness. The one with the coude point is generally satisfactory. As the object of the catheterism in the beginning is to prevent increase in the residual urine and consequent atony of the bladder, the employment of the instrument once or twice a day gen- erally will be sufficient. When voluntary urination becomes greatly embarrassed and painful, it is better to depend upon the catheter rather than to permit the patient to strain and congest the parts by voluntary efforts. The rule, however, in these cases should be to empty the bladder completely at each catheterization, and to employ it as infrequently as possible. As a rule, great comfort will be expe- rienced by the patient as soon as he becomes well established in his catheter-life. Attacks of bladder infection are, however, almost sure to occur from time to time as a result of some error in technic. After the back-pressure on the ureters and. kidneys has been removed by the avoidance of an accumulation of residual urine, such attacks are less dangerous for the reason that the infection generally remains limited to the bladder and posterior urethra, a situation in which it is readily amenable to treatment. If difficulty is experienced in the passage of the catheter, or in voluntary micturition, the occasional use of a full-sized sound will afford temporary relief. Permanent suprapubic or perineal bladder drainage is occasionally resorted to for relief of pain and retention in patients who are unable to withstand the shock of the more radical procedures. While catheterism and vesical drainage are often indicated in the old and feeble subjects of prostatic hypertrophy, most surgeons now recognize the fact that the safest procedure in the majority of instances is the operation of prostatectomy or surgical removal of the obstructing gland. The Bottini operation, or deep cauterization of the thickened neck of the bladder, formerly practised with con- siderable temporary relief has now been practically abandoned. The advantages of prostatectomy are the fact that it is the only procedure which actually removes the cause of the obstruction and gives permanent results; that, with our present improved technic, the mortality has been reduced to a point even below that of the Bottini operation ; and that when relief is once obtained, a recurrence of the symptoms is not likely to occur. It must not be forgotten, how- ever, that incontinence of urine may follow the operation, and that a perineal or suprapubic urinary fistula has occasionally remained. TUMORS OF THE PROSTATE GLAND 715 TUMORS OF THE PROSTATE GLAND. Carcinoma.- Cancer of the prostate, formerly supposed to be an extremely rare disease, is now known to he of fairly frequent occurrence. The investigations of Albarran and Hall and of Young have demon- strated that from 10 to 14 per cent, of all non-inflammatory senile enlargements of the prostate are carcinomatous in character. While cancer of the prostate may and frequently does begin as a malignant neoplasm, in a large number of instances it is engrafted upon a senile hypertrophy, particularly of the adenomatous type. This is clearly proved by the large number of reported cases where individuals, suffering for years from the characteristic symptoms of senile hypertrophy, aFe operated upon, and the tissue removed is later found to present the histologic evidences of beginning malignant change. These cases cannot be recognized clinically, as the malignant disease has not advanced to such an extent as to give rise to character- istic symptoms or signs. The cases which are easily recognized clinically present an en- tirely different picture. In these the process extends so rapidly to the very abundant lymphatic system of the pelvis that Guyon has suggested the term prostatopelvic carcinosis, and has strongly advised against any attempt at radical operation. Young believes that there is a stage of the disease between these two extreme types which can be recognized clinically, and in which the disease is still limited to the gland or its immediate vicinity. In these cases he believes that radical removal holds out some hope for permanent cure. Regarding the clinical course of the disease, it may be said to be comparatively slow, as many cases are on record where it has existed For four or five years, and as this is after its clinical recognition, the actual duration of these cases is undoubtedly much longer. » Symptoms. — The symptoms of cancer of the prostate, in its advanced stages, are characteristic. The occurrence of pain, frequency, hema- turia, partial obstruction, and the presence of a hard, nodular growth, involving the prostate, base of the bladder, and rectum, will enable the surgeon to diagnosticate the true condition. In the earlier stages, when surgical intervention alone holds out any hope for permanent relief, local symptoms may be absent, or only those of senile hypertrophy may be present. To the palpating finger the gland feels abnormally hard, and there may be an induration extending upward along the ejaculatory ducts, or, as Young has described it, an indurated plate between the seminal vesicles. In slightly more advanced cases pain over the distribution of the sciatic nerve may be present; also, slight hematuria, especially after instru- mental exploration, and a nodular feeling of the organ to the palpating finger. 716 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE Bone metastasis is quite common. Visceral metastasis and cachexia occur late in the disease. Prognosis. — Sufficient data are not available to enable one to formu- late any definite conclusion regarding the value of the modern radical operation. There seems to be no valid reason, however, for doubting that here, as elsewhere in the body, early and thorough extirpation of the disease may not effect a cure. Treatment. — When there is reason to believe that carcinoma has been engrafted upon a senile hypertrophy of the prostate, Young advises prostatectomy and the immediate examination by a frozen section of the tissue removed. If the microscope demonstrates the disease, the radical operation should be performed. In other cases, where the characteristic signs of carcinoma are present, radical removal should be undertaken, unless the growth has advanced so far as to render complete removal impossible. In hopelessly advanced cases perineal or suprapubic drainage will often give a large measure of relief. Sarcoma. — Sarcoma of the prostate is much rarer than carcinoma, the proportion being about 1 to 4. While in some cases the rapid growth of a soft tumor would suggest the probability of sarcoma, in most instances the disease cannot be distinguished clinically from carcinoma. The prognosis and treatment of this disease should be the same as in carcinoma. OPERATIONS ON THE GENITAL ORGANS. Castration. — An incision is made over the loose inguinal region or upper part of the scrotum in the line of the spermatic cord, including the skin and dartos. The cord and testicle are separated from their bed of areolar tissue and drawn outward through the cutaneous open- ing. The various tunics are opened over the upper part of the cord and the vessels and vas deferens ligated separately. The cord is then divided and the testicle removed, the scrotum drained through an opening made in the bottom of the sac, and the wound united with silk. If the castration is for malignant or tuberculous disease, the inguinal canal should be opened as in the operation for hernia, the cord followed upward to the internal ring, and drawn downward as far as possible and treated in the same manner. Inguinal or retroperitoneal lymph- node metastases, in cases of malignant disease, should be thoroughly removed. Epididymectomy. — The testicle is exposed as for castration, the cavity of the tunica vaginalis opened, the epididymis carefully dissected from the testicle and removed with as much of the vas deferens as is diseased. The wound is then closed with a small rubber tissue drain extending to the cavity of the tunica. Epididymovasostomy. — This operation is recommended for the cure of sterility due to inflammatory occlusion of the vas deferens in OPERATIONS ON THE GENITAL ORGANS 717 the globus minor. It can be performed with local anesthesia. An inci- sion is made through the posterior wall of the scrotum and the tunica vaginalis opened. The vas is next isolated, divided by an oblique incfsion, and the lumen still further slit up with fine-pointed scissors. The tissue at the head of the epididymis is next grasped by a small mouse-tooth forceps, and a small section removed by curved scissors. If a patent tube is opened, a small amount of yellowish fluid will now appear, which immediately should be examined by the microscope to demonstrate the presence of living spermatozoa. The open proximal portion of the vas is then placed over the opening in the globus major and held by a few fine chromic catgut sutures. In this operation great care should be used not to injure or wound the veins of the cord, on account of the danger of thrombosis, which seriously interferes with prompt recovery. As a rule, the wound is closed without drainage, a suitable dressing applied, which is held in place by a suspensory, and the patient treated as an ambulant case. Exposure of the Prostate and Seminal Vesicle.— This operation is accomplished best by the Zuckerkandl curved incision, extending across the perineal space from one tuberosity to the other, the summit of the curve being well above the anal orifice. The incision is gradually deepened to the end of the bulb, and the central tendon divided with scissors. Just behind the central tendon another point of attachment will be found between the rectum and the membranous urethra, the redo-urethral muscle. This should be divided close to the urethra, which allows the rectum to fall backward into the hollow of the sacrum, and greatly increases the operative space. The prostate is now easily ex- posed by blunt dissection, and, by carrying the dissection well above the upper border of the prostate, the seminal vesicles can be brought into view. In performing this operation the patient should be in the lithot- omy position with the thighs flexed as acutely as possible. A steel sound should be placed in the bladder as a guide and the rectum kept well out of the way by a retractor. Through this incision abscesses of the prostate or vesicle may be opened and drained. Removal of the Entire Genital Tract. — Removal of the entire genital tract is indicated when there is tuberculous disease of the testicle, vas, and seminal vesicle on one side only, without involvement of the pros- tate. The patient is placed in the lithotomy position and the seminal vesicle exposed by the Zuckerkandl incision, after which it is carefully separated from the prostate by blunt dissection, care being taken to avoid wounding the urethra and rectum. After the vesicle and the adjacent portion of the vas are dissected free, the position of the patient is changed and the regular operation for castration performed, the cord being followed upward to the brim of the pelvis by free dis- section of the structures in the neighborhood of the internal ring. The testical and vesicle are then grasped by the operator and a sawing motion made, which will quickly separate the deeper portions of the vas from the surrounding tissue, after which the cord is divided at 718 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE the internal ring and both ends removed. The wounds are then united as described above. Prostatectomy. — The suprapubic route should be chosen for large intravesical outgrowths; the perineal, for enlargements of the lateral lobes. Suprapubic Prostatectomy. — Suprapubic prostatectomy, by Fuller's method, is performed as follows: The bladder is opened above the I Fig. 328. — Young's prostatic tractor closed and ready for introduction. pubis as described on page 661. The prostatic enlargement is appre- ciated by the examining finger and the bladder wall incised, preferably by heavy scissors, from the lower margin of the internal urethral orifice, backward in the median line, over the tumor-mass. The forefinger of the right hand is next introduced through this incision, while the closed fist of the left hand makes firm upward pressure against the perineum. This forces the tumor high into the pelvis, where it generally can be enucleated by the finger of the right hand. All obstructing tissue should be removed and the urethra subsequently explored to insure its free- Fig. 329. — Same open. dom from projecting masses. A large perineal drainage tube is next introduced and the bladder irrigated for several minutes with hot salt solution to control the oozing. If the bleeding is not such as to neces- sitate packing the bladder, the suprapubic wound is partly united with two rows of sutures, and a single medium-sized rubber tube intro- duced and allowed to remain for three or four days, after which it is removed and the wound closed by tying a previously introduced pro- OPERATIONS OS THE GESITAL ORGANS 719 visional suture of silkworm gut, which should include skin, muscle, and bladder wall. The perineal tube should be allowed to remain in place for a week or ten days. J. Bentley Squire has modified this pro- cedure somewhat. After the bladder is opened he introduces the index finger into the prostatic urethra until the anterior limit of the Fig. 330. — Young's technic: prostate brought down and lateral incisions made in capsule. (After Young.) growth is reached. The urethral mucous membrane is then torn, and the prostatic enucleated from the triangular ligament backward toward the bladder. By this procedure he believes there is less injury to the vesical sphincter. Perineal Prostatectomy. — The simplest method of perineal pros- tatectomy is Alexander's operation. The patient is placed in the 720 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE lithotomy position. The membranous urethra is opened through a generous perineal incision and the finger introduced into the prostatic portion of the canal. The mucous membrane on the floor of the prostatic urethra and the capsule of the prostate are then torn by the finger-nail and each lateral lobe enucleated by the forefinger, while the mass is forced well downward by the left hand by suprapubic press- ure. After the prostate is removed the bladder is irrigated with hot sterile salt solutions and perineal drainage established. Fig. 331. — Young's technic: separation of capsule with blunt dissector. (After Young.) Parker Syms draws the prostate well downward in the perineal wound by traction on a rubber ball introduced into the bladder through the urethral wound, and subsequently inflated. This gives excellent control of the gland. Hugh Young employs a metal retractor (Fig. 328) which is shaped like a steel sound. This, when introduced into the bladder, is opened (Fig. 329), and with it the prostate often can be drawn downward to the margin of the cutaneous incision. In Young's operation the prostate is exposed as described above, and the retractor introduced through an opening made in the membranous urethra. By drawing OPERATIONS ON THE GENITAL ORGANS 721 the prostate well downward and elevating the handle of the retractor the entire posterior surface of the gland can be brought into view. He next makes two slightly diverging longitudinal incisions through the capsule, and by means of a blunt dissector separates the lobe from the capsule after which removal is effected by the finger or a pair of flat fenestrated lobe forceps (Figs. 330, 331, and 332). Young states that he is able by this plan to remove practically all enlarged prostates. He recently reported over 100 consecutive cases without a death. Fig. 332. — Young's technic withdrawing lateral lobes after being enucleated. (After Young.) Young's Radical Operation for Carcinoma of the Prostate. — The pros- tate is exposed as described in the previous section, the membranous urethra cut across, and the retractor introduced into the bladder. The handle is next sharply depressed and the puboprostatic ligaments divided. This enables the operator to draw T the prostate well down and often outside of the cutaneous incision. The bladder is then opened from in front, just behind the upper margin of the gland, and the trigone exposed. The incision is next carried downward on either side, and the floor divided just distal to the ureteral orifices. The sem- 46 722 DISEASES OF TESTICLE, SEMINAL VESICLE, PROSTATE inal vesicles are separated from their attachments and the vasa defer- entia divided as high up as possible. The entire mass, consisting of the prostate, vesicles, and vasa deferentia, is removed, and the large bladder wound reduced in size and united to the distal portion of the urethra by sutures. The levator muscle is drawn together by one or two heavy catgut sutures, a soft-rubber catheter introduced through the urethra to the bladder, the cutaneous wound partly united, and a small gauze drain inserted. CHAPTER XXVI. INJURIES AND DISEASES OF THE RECTUM AND ANUS. CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. The rectum is formed by the union of the caudal extremity of the primitive hind gut and the proctodeum or cutaneous anal depression. Arrest of development may result in stenosis of the canal, congenital stricture of the rectum; in the presence of a membranous septum, imperforate anus; or in complete absence of the anal depression, with or without the presence of a blind rectal pouch in the hollow of the sacrum. This pouch when present may or may not retain its original connection with the genito-urinary tract. In the former case the alimentary canal may open into the bladder, urethra, or vagina; in the latter, complete intestinal atresia is present. Treatment. — Congenital strictures (generally located about one inch above the anus) are to be treated by gradual dilatation. Membran- ous septa may be perforated and subsequently dilated. Blind rectal pouches should be sought for by perineal incision, and, when found, brought down and sutured to the skin of the perineum when this is possible. When the rectum is too short the opening may be estab- lished higher, as in the Kraske resection, or by inguinal colostomy. Communications with the bladder usually close spontaneously after a free exit is given for the intestinal contents. INJURIES AND DISEASES OF THE RECTUM AND ANUS. Wounds of the Rectum. — Injuries to the rectum are rare on account of its protected position. Lacerations about the anus and extending into the bowel may be caused by falls upon pointed objects, by automo- bile or railway accidents, and by other traumata. The writer has twice observed severe lacerations caused by the horns of an infuriated bull. Such injuries may involve the bladder or urethra, or may extend upward and enter the peritoneal cavity. The rectum not infrequently is injured during surgical operations, as in the removal of the prostate or in perineal cystotomy. In the treatment of wounds of the rectum the same surgical prin- ciples should apply as in other localities. If there is reason to believe that the peritoneal cavity has been entered, laparotomy should be performed and the rectal injury repaired from above. If the wound is confined to the lower portion of the gut, its site should be exposed by 724 DISEASES OF THE RECTUM AND ANUS a generous incision with partial resection of sacrum, if necessary, and the wound repaired by layer suture. In the extraperitoneal portion of the rectum repair is slower and leakage is apt to occur. Adequate drainage should, therefore, be employed in these cases. When the wound involves the sphincter muscle great care should be exercised to bring the divided muscular fibres together. If the circular fibres are completely divided, the ends retract, and must be sought for and identified by careful dissection. When foimd they should be brought together by one or more buried mattress sutures of chromic gut, after which the skin and mucous membrane should be united by silk. When considerable laceration or loss of tissue has occurred, or where the parts are hopelessly infected, the chief effort should be to combat the infection, the repair of the muscle to be under- taken at a later period. Rupture of the rectum without external injury has been reported in a few instances. Burkhardt collected 14 cases, 13 of which proved fatal. Severe straining at stool is given as the most frequent cause. Where the rupture occurs into the peritoneal cavity the indications are for laparotomy and suture of the bowel wound when this is possible. If local repair is impossible, colostomy should be performed. Proctitis. — Proctitis is an inflammation of the rectal mucous mem- brane, caused by extension of an infection from above (colitis) or one introduced from without (gonorrhea or venereal ulcer); from the presence of a wound or foreign body, a new growth, or ulceration. Symptoms. — The symptoms of proctitis are pain, rectal tenesmus, and the frequent passage of stools containing blood and mucus. Treatment. — The treatment should consist in removal of the cause, rest, rectal irrigation, and the use of suppositories of opium to control the pain and tenesmus. Hot sitz baths and fomentations to the anal region often afford marked relief. In the chronic cases injections of a solution of glycerite of tannin (1 to 20) will be of value in lessening the mucous secretion. Periproctitis. — Periproctitis, or ischiorectal abscess, is a septic inflam- mation of the cellular tissue in the ischiorectal fossa, caused by infec- tion from the bowel by perforations of the mucous membrane from fish-bones or other foreign bodies, from ulcerations, and from follicular abscesses; from infections from the genito-urinary passages, as extravasations of urine, periurethral abscess or prostatitis; or from infections from without, the result of wounds or severe contusions. Symptoms. — The symptoms of ischiorectal suppuration are pain, and tenderness in the neighborhood of the anus, with fever and general malaise. On palpation an indurated area can be felt on one side of the rectum, and the extent of the mass may generally be appre- ciated by the finger introduced within the bowel. Redness, swelling, edema of the skin, and fluctuation appear later, and spontaneous rupture may occur. Periprostatic abscess, and occasionally deep- seated suppuration from infection of the lymph nodes accompanying INJURIES AND DISEASES OF THE RECTUM AND ANUS 725 the internal iliac veins, may rupture through the pelvic diaphragm and give rise to ischiorectal suppuration. In these eases drainage is imperfect even after free evacuation of the ischiorectal focus, and symptoms of absorption continue until the pockets above the levator ani muscle arc thoroughly drained. Treatment. — Early incision and drainage constitute the only treat- ment of this condition. As the areolar tissue of the ischiorectal fossa is loose and easily broken down, extensive burrowing of pus takes place, requiring large incisions frequently on both sides of the rectum; and in chronic, long-standing cases the deepest recesses of the space should be freely exposed and packed. As the majority of these cases are caused by infection from the bowel, in many instances a fistula results, requiring subsequent treatment. Fistula in Ano. — Fistula in ano is a sinus passing from the rectum to a cutaneous opening in the neighborhood of the anus. The older writers were accustomed to describe three forms: a blind internal, a blind externa], and one open at both extremities (Fig. 333). It is obvious that only the latter form can properly be classed as a fistula. Blind internal sinuses generally result from rupture of an abscess Fig. 333. — Diagram of three forms of anal fistula. (Roberts.) A, complete fistula; B, incomplete internal fistula; C, incomplete external fistula. into the lectum; blind external sinuses practically never persist unless due to a foreign body, bone disease, or to a tuberculous, syphilitic, or actinomycotic focus. In the majority of instances a fistula is the result of an ischio- rectal abscess which has been caused by a break in the mucous mem- brane of the rectum. After the abscess is evacuated, mucus and intestinal matter continue to leak from the bowel into the abscess cavity, which prevents healing and results in the formation of a nar- row sinus lined with granulation-tissue. The sinus may be straight, easily admitting a probe; or it may be exceedingly tortuous and have several cutaneous orifices situated at a distance from each other. A small number of fistulas are tuberculous in origin. Diagnosis. — As a rule, the patients complain of nothing but a slight mucous or mucopurulent secretion, which constantly exudes from a minute opening, which may be situated in the scar of an incision or may be surrounded by a bluish elevated papule. In some cases the entire ischiorectal region is indurated and presents numerous fistulous openings. On rectal examination the finger may often detect an elevated papule which is the seat of the internal opening. The passage 726 DISEASES OF THE RECTUM AND ANUS of a probe from the external to the internal opening establishes the diagnosis. This, however, is often impossible without general anes- thesia on account of the tortuous character of the sinus and the sensi- tiveness of the parts. Treatment. — When multiple openings exist, these should be followed up and freely opened to the main focus; a grooved director should then be passed from the main focus to the internal opening, and all the tissues divided by passing the blade of the knife along the groove in the director. An effort should always be made to divide the sphincter muscle but once, and then transversely to the direction of its fibres. The entire sinus should be thoroughly curetted and touched with the actual cautery, or it may be completely dissected from the surrounding tissues and removed. The wound should then be tightly packed with sterile or iodoform gauze, and an external pad of gauze applied and held in place by a T-bandage. The bowels should be confined for three or four days, after which a purge and enema may be given. After each evacuation of the bowels the parts should be irrigated and the wound firmly packed to insure healing from the bottom. Suture of the wound after dissecting out the sinus with a view to obtaining primary union is successful in a certain number of instances. If this plan is followed, the bowels should be confined for from six to ten days. Considerable time may be saved by this procedure even if that portion of the wound nearest the bowel does become infected. It occasionally happens that the opening into the rectum is so high (three inches or more) that the ordinary method of treatment cannot be carried out. In these cases it is better to expose the opening into the rectum by a large incision and close it by layer sutures, or to perform an inguinal colos- tomy, and attempt to close the rectal wound from within through a large rectal speculum. Stricture of the Rectum. — Stenosis of the rectum, as in other portions of the alimentary canal, may be caused by new growths, by inflam- matory thickening of its walls, by a cicatricial contraction following the healing of an ulcer, or by outside pressure. Inflammatory or fibrous stricture, which alone will be considered in this section, is a fairly common affection, and in the majority of instances is the sequel of simple ulcer, dysentery, gummatous ulcer- ation, trauma, or chancroidal disease. The stricture may be situated in any part of the rectum, but is generally found within three inches of the anus. As a rule, the constricting band completely encircles the gut and is limited in extent, giving rise in some instances to a condition similar to that produced by a cord tied around the bowel. Symptoms. — The symptoms of stricture of the rectum are pain, a gradually increasing constipation with occasional attacks of diarrhea accompanied by tenesmus and the passage of mucus and blood, indefinite digestive symptoms, and in later stages a gradual distension of the abdomen. Defecation becomes painful and slow, great straining being required. INJURIES AND DISEASES OF THE RECTUM AND ANUS 727 The stools, when diarrhea is not present, are small in size and often flattened like ribbons. When the stricture is situated low down within reach of the examining finger, the diagnosis is easy. When higher up, the proctoscope reveals the pres- ence of a narrow opening sur- rounded by an indurated ring of cicatricial tissue. 1 Treatment. — Fibrous strictures of the rectum are best treated by gradual dilatation, solid rubber or gum-elastic bougies being em- ployed. When the stricture does not yield to this treatment linear proctotomy may be employed. This consists in dilating the sphinc- ter, exposing the interior of the gut by a wire speculum, or retrac- ting the walls by ordinary flat re- tractors, and incising the band in the median line. Following the operation the rectum should be fre- quently irrigated with warm salt solution, and full-sized bougies passed every second day until healing has occurred. In severe cases when extensive ulceration exists and the walls of the rectum are widely Fig. 334. — Kelly's protoscope. Fig. 335. — Pneumatic proctosigmoidoscope with electric light. infiltrated (a condition commonly found in old syphilitics), physiologic rest of the organ by a temporary inguinal colostomy, and frequent irrigation of the sigmoid and rectum from above, are to be recom- 1 Examination of the interior of the rectum should always be made in suspected disease of this portion of the alimentary canal. With the aid of the Kelly proctoscope or the electric sigmoidoscope the bowel can be easily and thoroughly examined for a distance of twelve or fifteen inches. When the short instrument is used, the patient should be in the knee-chest position. The longer tube may also be employed while the patient is in Sim's position (Figs. 334 and 335). 728 DISEASES OF THE RECTUM AND ANUS mended. In more advanced cases, where these measures are ineffec- tual, resection of the diseased" area is to be advised, as in cases of malignant disease. Ulcer of the Rectum. — Ulcers of the rectum develop as a result of a number of local and constitutional conditions. Of the former may be mentioned trauma from hardened feces, fish-bones, or other foreign bodies; portal congestion, giving rise to hemorrhoidal ulcers or vari- cose ulcers higher up in the rectum; dysentery, chancroidal disease, and acute proctitis. Of the constitutional causes may be mentioned tuberculosis, syphilis, actinomycosis, diabetes, chronic nephritis, and the condition known as marasmus. Carcinomatous ulcer will be con- sidered elsewhere. Simple or Non-specific Ulceration. — Simple or non-specific ulceration of the rectum is rare in childhood. It occurs most frequently in middle- aged females. It is generally associated with chronic constipation, a torpid liver, and digestive disturbances which result in a varicose condition of the veins in the lower segment of the rectum. If to this be added an abrasion of the mucous membrane, infection takes place, and an ulcer is formed with a round-cell infiltration of the submucous tissues. The process is prone to extend in the direction of the blood- vessels, and consequently tends to encircle the gut. If the ulceration is limited to the mucous membrane, recovery may occur; if, however, the deeper tissues are involved in the destructive process, healing may result in marked stenosis of the canal, a condition which has been described as fibrous stricture. Chancroidal Ulcers. — Chancroidal ulcers are exceedingly rare in this country. They occur most commonly about the anus, rarely above the sphincter muscle. In debilitated subjects they may spread rapidly and cause great destruction of tissue. Tuberculous Ulcers. — Tuberculous ulcers are almost always secondary to tuberculous disease elsewhere. They occur most frequently at or near the anal orifice, and are frequently associated with fistula 3 and marginal perianal ulcerations. When limited to the interior of the bowel, they occur as single or multiple oval, punched-out ulcerations with overhanging edges, which may coalesce, forming large irregular- shaped losses of tissue. In the upper part of the rectum they generally surround the gut. Syphilitic Ulcers. — Syphilitic ulcers are usually tertiary, are caused by a breaking down of gummatous masses, and may give rise to great destruction of tissue. They occur low down in the rectum, and are generally followed by a contracting scar which results in obstinate stricture. Tuttle calls attention to the fact that such ulcerations are frequently associated with a peculiar dry and brittle condition of the anal mucous membrane. Primary and secondary syphilitic lesions may also be found in the rectum, but rarely produce destructive ulcers. Mixed infection may occur in syphilitic ulcerations, and the resulting strictures may differ in no way from those resulting from simple ulcerations. IXJURIES AND DISEASES OF THE RECTUM AND ANUS 729 The ulcers resulting from actinomycosis are generally associated with extensive infiltrations of the perirectal tissues. Symptoms. — Ulcers of the rectum from whatever cause usually give rise to certain well-marked symptoms. Pain is generally present, more particularly in idcers situated low down within the grasp of the sphincter muscle. If high up in the rectum, the pain is often of an aching character, and may be referred to the penis, neck of the bladder, or coccyx. Tuberculous and syphilitic ulcers, as a rule, give rise to less acute pain than the other varieties. Diarrhea, with the passage of mucus and blood, is not infrequent. The diarrhea is most marked in the morning, and rarely disturbs the patient at night. Relaxation of the sphincter is a symptom in some cases. In all suspected cases the diagnosis should be confirmed by an ocular examination by means of the proctoscope. . Treatment. — Simple hemorrhoidal or varicose ulcers should be treated by rest in bed, frequent irrigation of the rectum with warm saline solution, and the local use of astringents by injection or suppositories. Injections of glycerite of tannin (1 part to 20 of water) or of mild solutions of silver nitrate are to be recommended; also suppositories of iodoform or tannic acid. Chancroidal ulcers should be touched w r ith pure carbolic or nitric acid, followed by irrigation and anodyne suppositories. Tuberculous ulcerations may be curetted and dusted with iodoform, although many cases are undoubtedly made worse by local measures. Cod-liver oil, creosote, and hygienic measures should be employed. In the gummatous stage of syphilitic ulcerations sal- varsan or the internal administration of mercury and potassium iodide will often be of marked value. As in the treatment of chronic ulcer of the leg, rest in the horizontal position will greatly facilitate the treatment of chronic rectal ulcerations. Fissures of the Anus. — Fissure of the anus consists in a small longitudinal ulcer of the mucous membrane of the anus, usually situated on the posterior aspect of the orifice between the folds of the puckered integument. It is often concealed from view, and may only be seen by drawing the folds well apart by the fingers. It is frequently associated with hemorrhoids or pruritus ani, and is caused generally by an abrasion from the passage of hardened feces. Symptoms. — The symptoms of fissure are a severe burning pain im- mediately after defecation, which may persist for several hours, the presence of a slight mucous secretion, and the occasional appearance of a few drops of blood after a constipated movement. Treatment.— The treatment should consist in absolute cleanliness, hot sitz baths, and stretching the sphincter under general anesthesia. In obstinate cases incision along the floor of the fissure with dilatation of the sphincter will generally effect a cure. Pruritus Ani. — Pruritis ani is an intolerable itching of the skin and mucous membrane of the anal margin without eczema or other cuta- neous lesions. It occurs chiefly at night, and frequently is associated with fissure or hemorrhoids, but may be wholly of nervous origin. 730 DISEASES OF THE RECTUM AND ANUS Treatment. — The treatment should embrace measures to improve the general health and nervous tone of the individual, and the local use of hot water, followed by the application of a solution of carbolic acid (1 to 100) on a soft linen compress. In obstinate cases which have resisted all efforts at palliative treat- ment, an operation, consisting of an incision through skin and sub- cutaneous tissue, completely surrounding the anus, may be performed, the object being to divide the superficial cutaneous nerves which supply the anal region. After removing a small segment of tissue. the wound is resutured, or may be kept open to heal by granulation. TUMORS OF THE RECTUM. Benign Tumors. — Of the benign tumors which occur in the rectum, adenomata are the most frequent. They may occur as single peduncu- lated growths or as multiple tumors involving a large extent of mucous membrane. The tumors are, as a rule, soft, freely movable, and if situated low down in the bowel may protrude through the anus. Papillomata, or villous tumors, angiomata, fibromata, myxomata, and lipomata, are rare. The term rectal polyp is used clinically to describe any soft pedunculated benign tumor growing from the mucous mem- brane of the rectum. In the majority of instances rectal polyps are found to be adenomata. Symptoms. — The symptoms of benign growths are chiefly those of a foreign body in the bowel. If the growth is situated low enough to engage in or protrude through the sphincter, pain and tenesmus may be present. If ulceration of the mucous membrane occurs, there may be hemorrhage. Stenosis of the gut is rare, and never gives rise to complete obstruction. In the majority of instances benign tumors situated well above the sphincter muscles produce no symptoms, and are discovered only as a result of systematic rectal examination by the finger or speculum. Treatment. — The treatment of polyps and other small growths should be complete removal, which is easily accomplished with scissors, cutting forceps, or the wire snare, if the growth is accessible. In tumors involving a large area of the bowel the growth may be attacked from behind by the Kraske procedure, or a resection may be necessary. Dermoids. — Dermoids of the rectum are rare. When they do occur they generally involve the posterior wall of the gut, and present, as a rule, long locks of hair which project into the lumen of the bowel and may protrude through the anal orifice. Dermoids occurring between the rectum and sacrum and coccyx (postrectal dermoids) are more common and attain a larger size. They may develop below or above the levator ani muscle. Those which develop below the muscle arise, as a rule, from the anococcygeal body, the remnant of the neurenteric canal. They are often spoken of as thyrodermoids on account of their resemblance in structure to thyroid tissue (Fig. 336). TUMORS OF THE RECTUM 7.31 Those which develop above the muscle often reach an enormous size. As a rule, they contain pultaceous material, hair, and teeth. Treatment. — The treatment of dermoids not involving the rectal wall is by enucleation after exposure of the cyst wall. In those involv- ing the wall of the gut partial excision will be necessary. The best exposure in these cases is to be obtained by the sacral operation described under the treatment of malignant neoplasms of the rectum. Malignant Tumors. — Carcinoma. — Carcinoma of the rectum is a fairly common disease. Tuttle states that nearly 5 per cent, of all cancerous growths occur in the sigmoid, rectum, and anal region. The disease presents several distinct varieties. Thus epithelioma occurs at the junction of the skin and mucous membrane at the anus, and differs in no respect from superficial epithelioma elsewhere. Adeno- carcinoma is the conlmonest variety found within the bowel. Xext in frequency comes scirrhus, the hard fibrous constricting growth; and lastly, the medullary or the very cellular variety. Cancer of the rectum Fig. 336. — Anococcygeal dermoid. is a disease of late middle life, occurring most frequently in individuals between forty and sixty years of age. It is slightly more common in men than in women. In the majority of instances it is located in the upper part of the rectum. Tuttle's tables show that 5b per cent, of the cases occur in the supraperitoneal portion, IS per cent, in the infraperitoneal portion, 15 per cent, in the sigmoid, and 9 per cent. at the anus. Metastasi> takes place through the lymphatics, at an early period in the more cellular growths, later in the fibrous and adenomatous varieties. The iliac and lumbar nodes are chiefly enlarged; the inguinal also if the disease involves the anus. Symptoms. — The symptoms of cancer of the rectum resemble at first those of hemorrhoids or ulcer, if the di-ease is situated in the lower segment of the tube. Thus there is more or less constipation deep-seated pain, hemorrhage, and tenesmus. If the growth is located higher up, the first symptoms are often those of stricture. The patient experiences more and more difficulty in obtaining a satisfac- 732 DISEASES OF THE RECTUM AXD ANUS tory movement of the bowels, with or without occasional pain and discomfort. Later, attacks of incomplete obstruction occur, with pain and general abdominal distention, which are usually relieved by cathartics and enemata. The stools become progressively smaller in size and amount, and the mass of retained fecal matter above the constriction may occasion irritation resulting in recurrent attacks of enteritis, during which diarrhea may be present, with the passage of mucus and blood. Thin, ribbon-shaped stools are occasionally observed if the growth is near the anus. Diagnosis. — The diagnosis generally can be made by digital exami- nation if the growth is accessible, by the proctoscope if beyond the reach of the finger. To the examining finger the growth generally gives the impression of a dense nodular mass involving all the coats of the rectum. In many cases the growth completely surrounds the bowel, constricting the lumen to a small size. The edges of the con- striction are frequently ulcerated and bleed easily when touched. Progressive anemia, loss of weight, and cachexia occur in this as in other cancerous affections, and metastases appear in the liver and other organs. Sarcoma. — Sarcoma of the rectum is a rare disease. It attacks by preference the lower segment of the organ, and arises in the submucous cellular coat. As in other situations, it presents varying degrees of malignancy according to the rapidity of its growth and its histologic characteristics. The growth of a spindle-cell sarcoma may be com- paratively slow, and recovery may follow its complete removal. Lymphosarcoma, on the other hand, is generally fatal in a few months after the diagnosis is made, in spite of any and all treatment. Diagnosis. — The diagnosis usually can be made by observing the rapidity of the growth, its situation in the lower segment of the gut, the fact that the mucous membrane is at first freely movable over the tumor mass, and by the absence of stenosis. In ulcerating soft sar- comata hemorrhage may be profuse. Treatment of Malignant Tumors of the Rectum. — Epithelioma of the anus, when limited in extent, should be thoroughly excised and the mucous membrane of the bowel drawn downward and stitched to the cutaneous margins; if more extensive, the disease should be attacked from behind by the Kraske method, soon to be described, and the lower portion of the bowel, the sphincter muscle, and a large area of surrounding skin removed. The healthy intestine should then be brought downward and a new anus formed either at the site of the old one or at a higher point through the sacral opening. In women a fair exposure of the lower segment of the rectum often can be made by a longitudinal division of the posterior vaginal wall. In the presence of malignant disease in the upper rectum or iigmoid four methods may be employed: First. — Extirpation of the lower rectum by the sacral route (Kraske). This consists in removal of the coccyx and a part (Hochenegg), or TUMORS OF THE RECTI M 733 the whole (Bardenhauer), of the lower one or two segments of the sacrum, separating the rectum from the surrounding tissues, removing the diseased area, and uniting the proximal and distal portions with two or more rows of sutures; or removal of the entire lower segment of the organ and creating a sacral anus. In this operation the upper portion of the rectum and a part of the sigmoid often can be brought down into the wound by opening the peritoneal cavity and severing all of the peritoneal attachments except the mesentery. When it seems desirable completely to remove the lower portion of the rectum and create a sacral anus, the upper segment of the bowel should be drawn outward at the upper angle of the incision, rotated on its longitudinal axis for about 180 degrees, and stitched to the cutaneous wound. After recovery from the operation this orifice can be guarded by a specially constructed truss with a pneumatic rubber ring. Second. — The abdominal or combined operation for growths in the upper rectum or lower sigmoid. The patient should be placed in the Trendelenburg posture and the abdominal cavity opened by a median incision extending from the umbilicus to the symphysis. The intestines are drawn upward and retained by large gauze pads, leaving the pelvic cavity well exposed. The area of the disease is next appreciated and the presence or absence of enlarged lymph nodes noted. An incision is then made along the left border of the mesentery, dividing the peritoneum only. This should extend upward to the region of the inferior mesenteric artery and all enlarged lymph nodes and surrounding areolar tissue removed. This is easily accomplished by gently stripping the subperitoneal tissues from the muscles by a gauze sponge as the bowel is being drawn over toward the median line, care being taken to avoid the ureter and superior hemorrhoidal vessels. The bowel is then clamped and divided well above and below the diseased area and the proximal and distal extremities inverted and closed by purse-string sutures. The diseased portion is next removed with the lymph nodes and areolar tissue, the two closed segments of the bowel approximated and a lateral anasto- mosis performed. When, on account of the low situation of the growth, this anastomosis is impossible, an effort should be made to draw the upper segment of the gut downward sufficiently to reach the anal orifice. If this is difficult or impossible, the descending colon can be still further freed by ligature and division of the superior hemorrhoidal artery near its origin, or even of the inferior mesenteric trunk, as recently suggested by Moynihan; the circulation in the lower por- tion of the sigmoid being carried on by a long arterial loop which runs parallel with the intestine and joins a similar loop from the colica media. When the upper loop is sufficiently mobilized, the peritoneum passing from the floor of the pelvis to the rectum is divided and the bowel separated from the levator muscle well down into the ischiorectal fossa. The patient is next placed in the lithotomy posi- 734 DISEASES OF THE RECTUM AND ANUS tion, and an incision made to the left of the anus sufficiently long to enable an assistant to still further separate and draw downward the rectal stump, which is finally inverted through the anus and cut off, care being taken to leave the sphincter muscle intact. A long-bladed forceps is next passed upward through the now denuded sphincter and the upper loop of sigmoid drawn downward and stitched to the cutaneous margin of the anus. The last step in the operation is to unite the peritoneum about the transplanted sigmoid, close the abdom- inal cavity, and insert a large mass of gauze for drainage in the perineal wound. This operation has been practically abandoned by surgeons on account of its high mortality and the fact that gangrene of the lower portion of the transplanted sigmoid is of frequent occurrence. A safer operation is the following : Third. — Complete removal of the lower segment of the bowel and the formation of an inguinal anus. Perform a laparotomy as in the preceding operation, expose the disease, follow up and remove the lymphatics to the junction of the inferior mesenteric artery and aorta. Next divide the sigmoid well above the growth, close both ends with purse-string sutures, and draw the upper loop outward through an intermuscular opening near the anterior superior spine, where it is fixed by two or three cutaneous sutures. The position of the patient is next changed as indicated above, the anus surrounded by an elliptical incision, which is extended backward to the coccyx, the entire lower segment of the bowel is then freed from its attachments and removed with its mesentery and all infected lymph nodes and areolar tissue in the manner just described, after which the peritoneum of the floor of the pelvis is united and the abdominal wound closed. The protruding end of the bowel should not be opened until the following day, after adhesions have formed, which completely shut off the peritoneal cavity. Fourth. — The fourth method, applicable to cases demanding complete excision of the entire lower segment, and whose condition contra- indicates the performance of a one-stage abdominoperineal resection with the formation of a permanent inguinal anus, is the two-stage operation; the first stage consisting of an incision through the left rectus, with exploration of the abdomen for possible metastases in the liver, retroperitoneal glands, or other structures, this step being completed by the formation of an abdominal colostomy; the second stage being performed ten days or two weeks later, and consisting in the complete excision of the rectum by the posterior or Kraske route; purse-string closure of the sigmoid distal to the colostomy opening, closure and drainage of the posterior wound. This method has been recently advocated and employed largely by a number of American and European surgeons. While rectal cancer has, in the past, been justly regarded by surgeons as an almost hopeless condition, the report of a recent series of 100 cases by Tuttle, with an operative mortality of 13 per cent, and 26 per cent, of cures three years after operation, gives much encourage- TUMORS OF THE RECTUM 735 ment, and shows the effect of the modern more radical methods of operation. In a certain percentage of cases, however, the surgeon is not consulted Until the disease is so far advanced as to be inoperable. A large measure of comfort can be given to these unfortunate indi- viduals by colostomy, which diverts the intestinal current, lessens the pain, and removes the distressing tenesmus. Hemorrhoids. — Hemorrhoids or piles, is a varicose dilatation of one or more of the veins in the lower portion of the rectal mucous membrane. The hemorrhoidal plexus is formed by a large number of veins which originate in small dilated pools or spaces located in the submucous tissue just above the anorectal junction. Each of these in health is about the size of a grain of wheat, and gives origin to a vein which passes upward, freely anastomosing with its numerous fellows, and eventually piercing the muscular coat of the bowel about three inches above the anus, to enter the radicals of the portal system. From the lower extremity of these small pools, minute anastomosing branches emerge which empty into the external hemorrhoidal veins located immediately under the integument at the anal orifice (Tuttle). Under conditions of portal congestion from chronic constipation, congested liver, cirrhosis, valvular disease of the heart, etc., these small veins become engorged, and permanent dilatation results. If the dilatation is limited to the external hemorrhoidal veins, the con- dition is described as one of external piles; if limited to the small venous pools within the rectum, it is spoken of as internal piles; if both are involved in the process, the term mixed piles is employed. In any of these situations thrombosis may occur, giving rise to bluish oval indurated masses, thrombotic piles, or infection may be added, giving rise to a condition of localized phlebitis, or inflamed piles. Occasionally a cluster of internal piles will be forced outward through the sphincter muscle, and by its contraction the mass becomes strang- ulated. Such masses often resemble a miniature bunch of grapes, and if not quickly reduced ulceration or sloughing may result. Symptoms. — Chronic dilatation of the hemorrhoidal veins is un- doubtedly present in many individuals without causing symptoms. In certain cases, however, there is a sense of weight and pain in the rectum, accentuated by defecation. This may persist for one or more hours and prevent sleep. If the cluster of internal hemorrhoids is large, the patient may experience a feeling of a foreign body in the rectum, which is not relieved by defecation. Hemorrhage due to superficial ulceration is a fairly constant symptom in internal piles, and in many cases it is profuse. If a mass of internal piles becomes strangulated, or if thrombosis and infection occur, the pain is greatly increased in severity, and is accompanied by local tenderness and fever. All of these symptoms are aggravated by defecation, walking, or sitting. The patient is confined to his bed, and often experiences great suffering for several days. An individual in this condition is generally spoken of as "having an attack 736 DISEASES OF THE RECTUM AND ANUS of piles." As a rule, the symptoms subside after a few days under appropriate treatment. In exceptional cases general infection may occur from disintegration of the septic thrombus and dissemination by the circulation. There is a popular impression that itching is a symptom of piles. While this symptom is frequently associated with piles, it is rarely due to the venous dilatation, but rather to an asso- ciated fissure, eczema, or pruritus. Intense itching is said to be occasionally caused by the small thick skin-tabs so frequently seen about the anus in individuals whose external piles have been spon- taneously cured by thrombosis and obliteration of the vessels. The diagnosis is easily made by inspection of the parts, drawing aside the folds of the anus, and instructing the patient to bear down. By this method not only the external piles are made prominent and filled with blood, but also the lower portions of the internal hemor- rhoids are brought into view. Unless the veins are inflamed, greatly thickened, or contain thrombi, they cannot be appreciated by digital examination. Examination by the short proctoscope in the knee- chest position is often negative, for the reason that in this position the veins are emptied and collapsed. Treatment. — The tendency to hemorrhoids should be combated by exercise, restricted diet, and measures to avoid constipation and portal congestion. Strangulated or inflamed piles should be treated by hot sitz baths, rectal irrigations when they are possible, moderate catharsis, and the local application of soothing ointments or poultices. If the condition is not such as to confine the patient to the bed, the following prescrip- tion will be found serviceable: " Ung. gallae, Ung. stramonii, aa 3j Sig.— Apply morning and night. Thrombosed and infected external piles are often promptly cured by incision, turning out the clot, and packing the wound with sterile gauze. The radical treatment of hemorrhoids consists in three procedures: obliteration of the lumen of the vein by the injection of carbolic acid; removal of the individual tumors; or removal of the pile-bearing area of the rectal mucous membrane. The injection method is largely employed by irregular practitioners, often with excellent results. It has the advantage that it allows the patient to be up and about during treatment. It consists in the in- jection of from 3 to 10 drops of a 20 per cent, solution of carbolic acid into the centre of the pile. The parts should be thoroughly disinfected and the needle introduced from below at a point where the hemorrhoid joins the healthy mucous membrane. Tuttle recommends the following formula: TUMORS OF THE RECTUM 737 Acid, carbolici (Cal verts), Acid, salicylici, Sodii boratis, Glycerine (sterile), 5ij 3ss 3i 5j— M. The immediate result of the injection is to cause a painful swelling of the pile, which subsides in two or three days, leaving only a thickened area of mucous membrane. Fig. 337. — Angiotribe. Removal of the individual tumors is accomplished by several methods. In all, the patient should be anesthetized and placed in the lithotomy position. The sphincter should then be thoroughly stretched, temporarily paralyzing its fibres. The simplest method of removal is by crushing the pile with the angiotribe (Fig. 337). The method by ligation and excision is the one most generally employed in this country. The pile is grasped by a pair of forceps and drawn downward. Its base is next encircled Fig. 338.— Smith clamp. by a cut which divides only the mucous membrane. A straight needle threaded with heavy silk is then passed through the base of the tumor and securely tied above and below, care being taken to avoid including in the knot any of the rectal mucous membrane. The sum- mit of the pile is then removed with scissors. The method by the clamp and cautery consists in grasping the summit of the pile by a pair of toothed forceps, drawing it well downward and applying a 47 7:;s DISEASES OE THE RECTUM AND A.XCS Smith clamp (Fig. 338) at the base. The summit of the tumor is then removed with scissors and the stump slowly cauterized with a cherry-red Paquelin point. After any of these methods a gauze-covered spool-shaped rectal tube should he introduced and held in position by four tape bands (Fig. 339). This prevents hemorrhage and allows the escape of flatus. It should be removed on the, fourth day and the bowel injected daily for one week with a solution of glycerite of tannin (1 to 20). Removal of the entire pile-bearing area of the rectal mucous mem- brane (Whitehead's operation) consists in making a circular incision ;it the margin of the mucous membrane and skin of the anus, separat- ing the mucous membrane from the muscular coat for a distance of from two to three inches, then cutting off the pile-bearing membrane, and suturing the healthy mucosa to the skin. This operation may be relied upon to cure the piles, but it has the disadvantage that it re- moves that portion of the mucous membrane which contains the Fig. 339.— Rectal tube. sensory nerves entering into what may be called the anal reflex, or the involuntary tightening of the anal orifice when the sensation of solid matter, fluid, or gas is felt in the lower rectum. The writer has seen several patients in whom rectal incontinence was present, yet who seemed to possess the ability voluntarily to contract the sphincter as well as before operation. Another objection to the operation is the possibility of infection, sloughing, and retraction of the mucous mem- brane, leaving a large circular granulating area which heals slowly and is invariably followed by a dense stricture. Prolapse of the Rectum. — Prolapse of the rectum is a projection downward of the mucous membrane of the bowel through the anal orifice. This occurs to a slight extent in healthy individuals during a constipated movement. The membrane, however, is quickly drawn upward by contraction of the sphincter, and no untoward symptoms are produced. If more of the mucous membrane is prolapsed, and it is not imme- TUMORS OF THE RECTUM 739 diately replaced by contraction of the sphincter, the condition is called prolapsus- ani. If the disease progresses and the entire wall of the gut is protruded, the condition is spoken of as prolapsus recti. The disease is more common in children than in adults, and is caused by constipation, severe rectal or bladder tenesmus from any cause, the presence of hemorrhoids or other rectal tumors, and from general weakness and muscular relaxation. In the early stages reduction is readily effected by gentle pressure with the fingers. In the later stages the prolapsed bowel becomes much thickened, and when reduced shows a strong tendency to reappear. Diagnosis. — The diagnosis is easily made by observing the presence of an oblong, sausage-shaped, pink or bluish mass protruding from the anus. Treatment. — The treatment should consist in removal of the cause when this is possible, the use of astringent injections, and the habitual employment of a commode so constructed that the seat is made to slant from behind forward at an angle of thirty or forty degrees from the horizontal. This prevents the patient assuming a position in which excessive straining is possible. If these measures fail, linear cauterization of the rectal mucous membrane for a distance of two or three inches above the sphincter is to be advised. This should be done under general anesthesia, the Paquelin cautery being employed, and three or four deep eschars made equidistant from each other. In children the cauterization may be accomplished by the application of pure carbolic acid to the pro- lapsed bowel by means of a glass rod or pointed stick. When the acid has produced its effect, it should be washed off with alcohol and salt solution, after which the prolapse should be replaced and the bowels confined for two or three days. Recurrence should be prevented by the use of laxatives, enemata, and the slanting-seat commode. In obstinate cases of prolapse of the mucous membrane the Whitehead operation described on page 738 has been recommended; also excision of a portion of the rectum. These methods, however, are inferior to sigmoidopexy, or the Moschowitz operation. The former consists in opening the abdomen by means of the intermuscular method, in the left inguinal region, drawing the sigmoid well upward and attaching its mesentery to the peritoneum and iliac fascia by means of two or three chromicized catgut sutures. Moschowitz approaches the problem of prolapse of the rectum from a different standpoint, considering it a true hernia, the sac of which is formed by the cul-de-sac of Douglas which, with its contents of small intestine, pushes downward the anterior wall of the rectum until finally it protrudes through the anus, the greater portion of the prolapsed tissue being formed by the anterior wall of the rectum and not the posterior. With this conception of the pathology, he has devised an operation which consists in obliteration of the cul-de-sac of Douglas through a 740 DISEASES OF THE RECTUM AND ANUS median laparotomy wound. With the patient in a high Trendelenburg position, and the abdomen opened, the rectum is pulled upward a far as possible, and a series of sutures placed purse-string fashion to obliterate the cul de sac, commencing near the bottom and carried upward as high as the posterior surface of the uterus, in the female, or the base of the bladder, in the male. Laterally, the suture includes the pelvic fascia and posterolateral wall, and anterior walls of the rectum. Care must be taken to avoid injury to the ureters or to the iliac vessels. This procedure not only obliterates the cul-de-sac and keeps the intestine out of the pelvis, but also serves to anchor the rectum and the cul de sac to the pelvic fascia laterally. No attempt is made to do anything to the protruding mucous membrane. The results of this operation have been most satisfactory in cases of true prolapse in which all the layers of the rectal wall are involved. CHAPTER XXVII. DISEASES OF BONE. INFLAMMATION OF BONE. Acute Osteomyelitis. — Acute osteomyelitis is an infectious inflam- mation of bone. The older surgeons were accustomed to describe three varieties of the disease: periostitis, or inflammation of the peri- osteum; osteitis, or inflammation of the denser portion of the bone; and osteomyelitis, or inflammation of the bone-marrow and cancellous tissue. A better understanding of the pathology of the affection, however, has demonstrated that these are simply different stages of the same pathologic process, which at one time or another generally involves all of the structures of bone. Septic processes in bone differ in no respect from similar processes in the soft parts, except in so far as their symptoms and results may be modified by the unyielding nature of the tissue. Two forms of the disease are described, the traumatic and the non-traumatic or idiopathic. The former variety occurs obviously at any age; the latter is commonest in children and young adults. The cause of acute osteomyelitis is invariably the invasion of the tis- sues by pathogenic micro-organisms, either through a wound exposing and injuring the bone, through the blood current, or through the lymphatics. Of the various micro-organisms which may give rise to osteomyelitis, Staphylococcus pyogenes aureus is the one most frequently found; the others in the order of their frequency being the strepto- coccus, the pneumonococcus, the typhoid or colon bacillus. The pro- cess may begin in any part of the bone; but in the non-traumatic or so-called idiopathic cases the infection usually first occurs in the interior, and in the majority of instances near the most active epiphysis. The first result of the microbic invasion is a reactionary hyperemia and the occurrence of an inflammatory exudate. Owing to the un- yielding nature of the tissues this at once produces sufficient pressure greatly to impede or totally arrest the circulation, and a more or less extensive necrosis of the ischemic tissue takes place. If the area of necrosis is small and limited to the thin cancellous structure and bone-marrow, a circumscribed focus of suppuration results (bone- abscess). At a later period this abscess, unless relieved, becomes sur- rounded by a layer of dense bony tissue, forming a protecting capsule. In rare instances this sclerosis may extend and involve a large part of the shaft of the bone. When the disease involves a large area, as the diaphysis of a long bone, the pus rapidly extends in the direction 742 DISEASES OF BONE of least resistance, which is along the medullary canal (Plate XXII). A barrier is reached at the epiphysis, as septic inflammations rarely pass this point. The infection, as a rule, burrows outward through the cortex, and often just beneath the epiphyseal cartilage until the external surface of the bone is reached. Here it may give rise to sup- puration, which spreads rapidly beneath the periosteum, separating it from the bone (subperiosteal abscess), and when the tension causes a rupture of the membrane it spreads between the muscular and fascial planes, and may eventually discharge on the surface of the limb. Septic involvement of a neighboring joint may rarely occur, giving rise to pyarthrosis, which is not infrequently overlooked. This occurs more often in adults and when the offending organisms belong to the strepto- coccus group. In severer cases, unless relieved by prompt surgical intervention, the area of necrosis extends rapidly, and may involve a large portion or even the entire diaphysis of the bone. In these cases an acute hyperemia occurs above and below the necrosed area, which eventually results in a softening and lique- faction of the tissues at the junction of the dead and living bone. The periosteum becomes congested and produces an abundant exudate, which, later, becomes calcified and forms a cylindric bridge between the proximal and distal healthy portions of the bone. This bony case or involucrum encloses the necrosed portion of the shaft, or sequestrum, which sooner or later becomes loosened and lies free within its bony envelope. The involucrum is perforated at one or more points allowing the escape of the pus which is always present within its cavity. In the very acute cases septic thrombi form in the veins situated within the bone and in the surrounding soft tissues. These may soften, and small portions may be carried by the general circulation to distant parts of the body, giving rise to metastatic accidents. In extensive osteomyelitis of the larger bones, the resulting toxemia may be so great as to cause death in two or three days. Another type which is rapidly fatal is that which occurs in cases of virulent streptococcus septicemia. In these cases the bone foci may be small, often multiple, and not infrequently are the only discernible lesions present. Symptoms. — In the so-called idiopathic cases the symptoms at first are simply those of a severe infectious disease; chills, fever, and prostration may occur without local pain or other evidence pointing to the seat of the lesion. In the most virulent cases the temperature may rise to 105° or 106° F., and the toxemia may be so rapid and profound as to cause delirium and stupor before the patient experiences pain or is able to indicate its location. In these cases ulcerative endo- carditis and a general petechial eruption are frequently found at an early period, and point to a rapidly fatal termination. In the less virulent cases pain is an early symptom, and varies in severity from a dull aching sensation to the most acute suffering. With the pain there is more or less tenderness of the affected limb, easily appre- PLATE XXII £ r. i Acute Osteomyelitis of Tibia. Colored photograph of a fresh specimen removed from a child six years of aye. (Lumiere process.) INFLAMMATION OF BONE 743 elated by pressure over the bone, or by forcibly striking the sole or palm of the extremity in an extended position. Edema and a slight lividity of the skin are noticeable in some cases. Edema of the peri- osteum, seen on exploratory incision, is one of the most reliable signs of bone infect inn. In the later stages deep-seated or superficial fluc- tuation may be made out, and a palpable thickening of the shaft of the bone is present. In all acute cases, except the extremely virulent, a marked leukocytosis is present. In the severest intoxications, how- ever, occurring in individuals with greatly diminished vital resistance, leukocytosis may be absent. When the disease follows a compound fracture, amputation, or other bone lesion, the local symptoms are generally the first to excite the suspicion of the surgeon. In these cases there are evidences of wound-infection, deep-seated pain over the affected bone, and general toxemia. The degree of the latter is rarely as severe as in the non-traumatic cases for the reason that the products of inflammation find an exit, though often an imperfect one, through the open extremity of the medullary canal. Treatment. — The treatment of osteomyelitis depends upon the stage of the disease, the virulence of the infection, the bone or bones involved, and upon the age of the individual. The acute stage of necrosis and general toxemia, and those cases of acute bacteriemia with a bone focus or foci, demand, as any other acute suppuration, thorough drainage, which is accomplished by incising the soft parts and the periosteum and removal of the bony cortex with chisel, gouge, and mallet, until the healthy marrow is exposed at either end of the incision. In as much as the marrow spaces communicate throughout it is undesirable to curet the medullary cavity, since the endosteum upon which the inner cortex of the bone depends for growth, just as the outer cortex depends upon the periosteum, is destroyed by the procedure. The endosteum is already destroyed in places by the suppuration and its vitality lowered by the infection. Curetting its surface only destroys it further, and opens up new avenues into which the infection spreads. The infected area having been thoroughly exposed, proper drainage should be instituted depending upon the site of the infection. This is best accomplished by rubber flam, rubber tubes, or gauze and the application of sterile dressings moistened in a weak, warm, antiseptic solution. The infection usually extends close to the epiphysis, which may rarely be involved in the suppurating process. Should it become involved, the adjacent joint is apt also to become infected. The adjacent joint, however, may, in the early stage, contain fluid which subsides spontaneously after the primary focus has been properly drained. If the epiphysis and joint become involved, the operative procedure must be extended to them, removing a portion of the epiphysis and instituting proper drainage of the joint by arthrotomy. 744 DISEASES OF BONE Great care must be taken in all cases not to injure the epiphysis where it is not involved in the suppurative process. This is especially true in the region of the knee, where the greatest growth occurs from the lower epiphysis of the femur and the upper epiphysis of the tibia. The upper diaphyseal part of the tibia and the lower diaphyseal portion of the femur are both extremely common sites of acute septic osteomyelitis. In the early acute stage with the above treatment, occasionally one is fortunate enough to have the bone granulate up from the bottom and healing take place. This, however, is the exception, as seeondary operations for removal of sequestra are generally necessary. The healing varies considerably with the age of the patient, and the bone involved. In young children with growing bones, the process of repair and healing usually takes place. Even in children, the femur, possibly due to the difficulty of thorough drainage, does not repair so kindly as do many of the other bones. In adults, due to its dense cortex with its poor blood supply, and the injury to end- osteum by the suppurative process, secondary operations for removal of sequestra and the institution of drainage are usually, indeed almost always, required, as the process usually passes into a chronic sup- purating condition requiring repeated operations extending over years. This is one of the most difficult conditions in surgery in which to effect a cure, as it may recur in our experience after remaining latent for a period of twenty years. There is another phase quite rare, and even more acute than the stage above described, which is usually fatal. That is those cases in which there is an acute streptococcus infection of the blood with bone foci, as mere incidents. Manifestly, here the primary condition is the bacteriemia. The same organism can be recovered from the blood and the bone focus upon culture, and is in our experience usually a streptococcus. Drainage of the bone focus, general supportive treat- ment, and vaccines, offer the most hope. Passing from the acute stage where drainage has been established by operation or spontaneously, when the general condition of the patient has improved and the periosteum begun to thicken prepara- tory to the formation of an involucrum, other methods of treatment are available, depending upon the extent of bone necrosis and the thickening and calcification of the periosteum. When the sequestra are small, a spicule or thin plate involving only a portion of the thickness of the cortex, they may be lifted from their bed by the granulations, and the removal of them is all that is neces- sary, provided the repair is sufficient to obliterate the cavity. The filling of the cavity with the Moset ig-Moorhof mixture, though it is more useful in the more chronic conditions, will here greatly aid the reparative process. More frequently, however, the sequestrum is composed of the entire thickness of the cortex for some distance, or throughout its I\'FLAMU.\TI<)\ OF lldXE 745 entire length. During the early stage of this condition while the perios- teum, though thickened, is still pliable and plastic, the subperiosteal resection (Nichols) is the method of choice where the hone involved i- supported by a parallel bone as in the leg and forearm. The time for the operation varies in different individual-, depending upon the rapidity of the periosteal repair. The .r-ray shadow, and the puncturing of the involucrum with a needle to ascertain its thick- ness, as suggested by Nichols, will greatly aid in determining the time — usually from five to eight weeks from the onset of the disease. The extent of the operation depends upon the length of the shaft involved; the whole diaphysis may be necrotic and require removal from epi- physis to epiphysis or a portion only may require removal. Upon incising the soft parts and the periosteum, the latter is care- fully stripped from the shaft with curved elevators so as not to injure the periosteum. The ease with which it strips from the shaft is a practical guide to the extent of the process; as the limits of the pro- cess are reached, the periosteum becomes more adherent. The diseased portion of the shaft, the periosteum having been separated, is then removed with a Gigli saw, or chisel, and the edges of the periosteum brought together with interrupted sutures of catgut. If the whole shaft is involved, it usually can be removed by grasping it with strong forceps, using a rotatory motion to free it from the epiphysis. In the formation of the new bone, since the growth takes place from the epiphyseal ends, and more particularly from the epiphyseal end from which the bone normally grows most rapidly, it is desirable to leave, if possible, a portion of the diaphysis, but it is not essential to the formation of a new bone. The new formed periosteal shaft is usually somewhat irregular in contour, and there may be a slight bowing of the limb toward the affected bone due to the growth of the parallel and unaffected bone. This new forming bone fractures easily, but the fractures, on the other hand, repair with great rapidity, and are only detected, as a rule, in the course of a*-ray examinations. The ultimate results are excellent; as regards function, there is usually but little if any shortening; there is no recurrence of the suppuration and, as a rule, the lesion when once healed, remains so (Tie?. 340, 341, 342 and 343). While the above operation can be performed upon the humerus, it must be undertaken at a later date when the involucrum is thicker. It is only applicable in selected cases; it is much more liable to fail, and if undertaken a proper appliance should be used to overcome the shortening from muscular contraction. A bone transplant may be inserted or an intermedullary splint of metal or ivory may be intro- duced to be removed when the new periosteal shaft is sufficiently rigid to withstand the muscular contraction, or the shortening may be overcome by a properly applied plaster of Paris splint, orthopedic- appliance, etc. (Figs. 344 and 345). 746 DISEASES OF BONE In the late, or chronic stage, there is a rigid involucrum enelosing the sequestrum, accompanied by sinuses, and a foul, purulent fl l>JH ■ ^ ^^^ Ak^ v i i Fig. 347. — Osteitis deformans (Paget' s disease). able similarity in the pathologic changes in the members of each class, the individual differences being largely in the location of the lesions and the age at which thev appear. Osteitis Deformans — Osteitis deformans, first described by Paget, is a disease of adult life, characterized by a slow and painful enlarge- ment of certain bones of the body. The changes in the bones con- sist in atrophy of the cancellous tissue, resulting in the formation of large medullary spaces and canals, with more or less softening and later hyperplasia of the compact tissue, increasing to a considerable degree NUTRITIVE DISTURBANCES IN BONE 755 the size of the bone. The disease attacks by preference the long bones of the skeleton, which may become curved by the weight of the body; also the cranial bone", the spine, and pelvis. Great thickening of the skull, curvature of the spine, and bow-legs are the chief deform- ities. The disease is progressive and is more frequent in men. Frac- tures of the affected bones occur from apparently trivial traumata. While little is known regarding its etiology, it is almost always asso- ciated with an advanced degree of arterial sclerosis (Fig. 347). Symptoms. — The symptoms are early pain and discomfort in the affected bones; later, deformity and a characteristic attitude and gait. The head is bowed forward, the spine curved, the shoulders high, and the knees widely separated. The patient walks with a slow, waddling gait. Treatment. — The treatment, up to the present time, has been abso- lutely unsatisfactory. Only hygienic measures are to be recommended. Acromegaly. — Acromegaly is a chronic disease of the skeleton, char- acterized by progressive enlargement of the bones of the hands and feet, of the face, and often those of the trunk and extremities. The disease is now generally regarded as being due to hyperpituitarism, as it is often associated with new growth or other gross change in the hypophysis. Symptoms. — The symptoms begin, as a rule, in early adult life, and consist in deformities of the affected regions. The hands and feet enlarge, the under jaw becomes prominent, the nose and lips become thickened, and the eyebrows massive. The voice becomes coarse and deep in pitch. Later, a certain amount of mental sluggishness is apparent and the sexual function may be impaired. In some cases headaches are a prominent symptom, and glycosuria often is present. When due to a neoplasm of the hypophysis a bitemporal hemianopsia frequently develops, with other general symptoms of brain tumor. The prognosis is grave, but in many instances the progress is slow, and the duration of life may not be shortened. Treatment. — The treatment in the past has been unsatisfactory. Gushing has recently advocated operative treatment, with a view to exposing the gland, removing a part of the tumor or effecting decompression by extensive removal of the anterior wall of the sella turcica. Recently he exhibited to the Society of Clinical Surgery a patient upon whom he had thus operated, with marked relief of symptoms. Leontiasis. — -Leontiasis is a progressive hypertrophy of the bones of the upper part of the face, giving rise to a peculiar lion-like counte- nance. The bone changes are similar to those of the preceding condi- tions and, in their development, often encroach upon the orbits, accessory nasal cavities, and foramina. In the latter situation, pressure upon sensory nerve trunks may give rise to neuralgic pains. Treatment. — The treatment of leontiasis is undeveloped. The writer has, on two occasions, exposed and removed hypertrophied 756 DISEASES OF BONE areas which were causing noticeable deformity. The appearance was temporarily improved, but the disease continued to progress. Osteomalacia. — Osteomalacia is a rarefying degeneration of the bones of the skeleton, resulting in enlargement of the medullary spaces, replacement of the calcareous elements by a highly vascular fibro- cellular tissue, and a thinning of the cortex. This results in softening, deformity, and a tendency to fracture on the slightest provocation. Little is known of its etiology, except that it is apt to follow multiple pregnancies in rapid succession. This has given rise to the theory that it may be due to an excess or a diminution of an internal secretion possibly that of one of the sexual organs, or, as suggested by Bossi, of the suprarenal gland. The early symptoms of the disease are pain in the affected bones, generally the pelvis, weakness, and a peculiar characteristic attitude and gait. The patient will bend forward and walk slowly with short steps, often supporting the body by leaning with the hands upon nearby objects. The treatment should consist in the cessation of lactation, the admin- istration of phosphates, cod-liver oil, and iron, with sea-bathing and other hygienic measures. Bossi and Rebaudi report a cure by the hypodermic injection of adrenalin. Osteogenesis Imperfecta. — A congenital condition similar to osteo- malacia, resulting in atrophy of the bony cortex and extreme fragility of the bones. The children, as a rule, are undersized at birth, may be deformed (short legs), and are often mentally deficient. Fractures occur on the slightest violence; not infrequently one or more bones are broken at the time of birth. There is no satisfactory treatment for this condition. Chondrodystrophia. — Sometimes called congenital rickets. A rare condition of malnutrition during intra-uterine life, resulting in an arrest of development of the long bones, particularly those of the lower extremities. Most of these children are stillborn. When they survive they are dwarfed, with bow-legs, short, curved arms, and sunken noses. They generally exhibit also a peculiar deformity of the hands, called by the French main-en-trident, in which the entire hand is short- ened and the fingers all about the same length. The spine is frequently curved, the abdomen prominent, giving the deformity described as spondylolisthesis. Rachitis. — Rachitis is a constitutional disease, which may rarely be congenital, but is generally due to defective nutrition during infancy, resulting in delayed calcification of the bones, faulty epiphy- seal growth, and various deformities of the skeleton. Frichsen has described the condition as follows: "The essential features of the process are, first, an exaggeration of the processes immediately pre- paratory to the development of new bone; secondly, an imperfect conversion of the preparatory tissue into true bone; and thirdly, a NUTRITIVE DISTURBANCES IN BONE 757 great irregularity of the whole process." There are thickening and deformity of the epiphyseal cartilages, thickening and hyperemia of the periosteum, enlargement of the medullary spaces, and a condition of sponginess and hyperemia of the cortex. Symptoms. — The early symptoms of rachitis are digestive disturb- ances, flatulence, diarrhea or constipation, sweating about the head when asleep, delayed dentition, delayed closure of the fontanelles, and delayed walking. The deformities consist of enlargements at the Fig. 348. — Rachitic deformity of the legs. epiphyseal junctions, chiefly observed on the thorax at the points of union of the ribs and costal cartilages (rachitic rosary), at the lower extremity of the tibia, and lower extremity of the radius; irregulari- ties in the outline of the skull, which may be shortened anteroposte- riorly or elongated; the forehead is often flat, high, and square, with or without supra-orbital bosses; the thorax and pelvis are deformed; there is curvature of the long bones, especially of the lower extremity, which is generally the result of bending from too early attempts at walking, or from faulty postures or muscular traction. There are 758 DISEASES OF BONE enlargement of the abdomen, and a bulging of the lower ribs, giving rise to an apparent constriction opposite the attachment of the dia- phragm (Harrison's sulcus). Rachitic children who walk frequently suffer from anteroposterior or lateral curature of the spine, from bow- leg, knock-knee, and Hat foot (Fig. 348). Treatment. — The treatment of rachitis in the early stage should be to give the best possible diet, which should always include orange- juice and meat broths; to administer iron, cod-liver oil, and phos- phorus; to give daily salt baths and general massage; and to keep the child as much as possible in the open air and sunshine. Efforts at walking should be discouraged until the nutritive disturbances have been corrected. In the early stage of bony deformity, when the bones are soft and yielding, much may be accomplished by manipulation, braces, and plaster casts, especially in deformities of the extremities. At a later period os- teotomy or osteoclasis may be necessary. Cartilage. Cartilage. TUMORS OF BONE. Osteoma. — Osteomata, or bony tum- ors, are, as a rule, either calcified chondro- mata or bony outgrowths at points of attachments of muscles; the former occur in the long bones at or near the epiphy- seal lines or in the flat bones in the neighborhood of cartilaginous tracts, and are generally connected with the bone by a plate of cartilage; the latter are frequently found arising from the adductor tubercle of the femur or from other points of muscular attachment, are often surrounded by a cartilaginous capsule, and are occasionally covered by bursse. Osteomata are slowly growing tumors, which, however, may reach an enormous size. They are innocent in character, and only produce pain and other disturbances by pressure on neighboring structures (Fig. 350). Chondroma. — Chondromata, or cartilaginous tumors, are frequently encountered growing from the long bones, generally from the neigh- borhood of an epiphyseal line. They are encapsulated, and often occupy hollowed-out spaces in the bone. These tumors are most frequently seen growing from the small bones of the hand, and are commonly multiple (Fig. 351). They may reach a large size and cause much discomfort. They are always innocent, but should be removed if they produce inconvenience. Chondromata may rarely Fig. 349. — Exostosis of adduc- tor tubercle of femur: its surface was clad with cartilage and sur- mounted by a bursa. (Orlow.) TUMORS OF BONE 759 develop in the interior of the large bones in the majority of instances at or near the epiphyseal line. Here they may expand the cortex and Fig. 350. — Radiograph of exostosis of shaft of femur. Fk;. 351. — Chondroma of hand. 760 DISEASES OF BONE give rise to symptoms and signs closely resembling medullary sarcoma (Fig. 354). Myxomatous degeneration may occur and give rise to a bone cyst. Fibroma and Lipoma. — Fibromata and lipomata are occasionally found growing from the periosteum, but differ in no respect from similar growths in other tissues. Bone Cysts. — The majority of bone cysts occur in connection with that condition described as ostitis fibrosa. In this condition, which is thought by some to be due to a chronic infective process, the medulla of the bone is partly replaced by fibrous tissue. This may expand the bone in places and result in an atrophy of the cortex. Later degen- erative changes result in the formation of single or multiple cysts. These cysts are of fairly frequent occurrence in certain long bones, and when they reach a sufficient size to be recognized clinically, they may or may not present a definite fibrous lining membrane. This membrane may contain small masses of cartilage or newly formed bone, and in nearly all cases giant cells. The fluid is reddish or brown- ish in color, but true blood cysts never occur in this condition. Of the rarer varieties of bone cysts may be mentioned, the degen- erated myelomata, and chondromata; the cystic changes in a medul- lary round or mixed-cell sarcoma (which not infrequently are true blood cysts), the occasional cysts which result from a subperiosteal hematoma, the bony wall being partly formed by the surrounding calcified periosteum; and the cysts rarely found in Paget's disease, osteomalacia, arthritis deformans, and in the callus of fractures. The cysts associated with ostitis fibrosa occur most commonly in the humerus, femur and tibia; cartilaginous cysts in the phalanges; degen- erated myelomata in the clavicle. Symptoms. — The disease is often preceded by a history of trauma. While pain in the bone may be present, in the majority of instances swelling is the first manifestation of the disease noted by the patient; spontaneous fracture is frequent. In cystic disease, the bone is generally enlarged and the cortex often markedly atrophied, giving rise to the egg-shell sensation on palpa- tion. This, with the similar circumscribed light area in an x-ray plate, will often lead to the diagnosis of a solid tumor of bone, from which the cases are with difficulty differentiated. Treatment. — The treatment consists in freely opening the cyst, curetting all diseased tissue to normal vascular bone, and treating the cavity as those resulting from osteomyelitis. If the disease is proved to be sarcoma, amputation should be performed in all but the giant-cell variety. Malignant Tumors. — All primary malignant tumors of bone are of mesoblastic origin ; the carcinomata occur only as secondary metastatic deposits. Sarcoma. — Sarcomata may arise from the periosteum and gradually extend around the bone; or they may develop from the cancellous TUMORS OF BONE 761 tissue of the medullary canal and by their growth expand the cortical shell. The former are called peripheral or periosteal sarcomata; the latter, central <>r medullary sarcomata. Periostea] sarcomata arc more frequent in the diaphyses of the Long bones, and by their growth develop around the shaft, which may be seen by the x-rays to present a fairly normal appearance in the centre of the tumor. Exceptionally they grow from a limited portion of the cortex and present well-marked oval tumor- Fig. Fig. 352. — Periosteal sarcoma of tibia. 352). In central sarcomata the growth distends the bone often to an enormous size, and the surrounding capsule of compact tissue may become so atrophied as to give to the examining hand the sensation of a crackling egg-shell. On .r-ray examination the fusiform dilata- tion of the cortex can be readily made out Fig. 353 1. Periosteal sarcomata are most frequently of the round-cell variety; they often follow an injury, grow rapidly, and are extremely malignant. Less frequently they are made up of spindle or mixed cells and are less 762 DISEASES OF BONE malignant. They commonly present, in their interior, bony trabecular growing at right angles to the shaft. Central sarcomata are most frequently of the myeloid type. They develop commonly in the ends of the long bones or in the horizontal ramus of the mandible, grow slowly, and while they cause extensive destruction of bone, rarely invade the articular cartilage and never metastasize. Of late most surgeons have placed them in a separate class and designated them myelomata, to distinguish them from the truly malignant round, spindle or mixed-cell varieties. Less frequently Fig. 353. — -Radiograph of early central sarcoma of humerus. the round-cell or mixed sarcomata are found developing from the centre of the bone; generally, however, from the shaft. Sarcomata apparently occur in the bones most liable to injury; thus, of the long bones, the femur, tibia, and humerus are the ones in which the disease is most frequently encountered; next in frequency come the radius, ulna, and clavicle. Of the other bones, the superior and inferior maxilla, the ilium, and spine are frequently the seat of the disease. In the long bones the disease is generally located near an active epiphysis, as the lower extremity of the femur or radius and the upper extremity of the tibia or humerus. TUMORS OF BONE 763 Aneurism of Bone is a term formerly much employed to designate certain highly vascular types of medullary sarcoma, in which pulsa- tion is present or a bruit heard on auscultation. As a rule these tumors are of the round- or spindle-cell variety, although these symp- toms have been observed in myeloid sarcoma. Spontaneous fracture is frequent in these cases — and blood cysts are occasionally found in their substance. Diagnosis. — The diagnosis of bone sarcoma in the early stage is often impossible, the chief difficulty being in excluding chronic osteomyelitis, gumma, and, when the disease is located in the extremity of a bone, chronic dis- ease of the joint. The two chief symp- toms are pain and tumor. Gross stated that pain is the initial symptom in Fig. 354. — Radiogram of chondroma of bone. Fig. 355. — Sarcoma of femur. two-thirds of the cases, tumor in one-third. In the writer's opinion these figures should be reversed, as a tumor is often present when the patient first complains of pain, although unnoticed up to that time. Regarding rapidity of growth there is much variation. The giant- cell tumors develop very slowly, several years often elapsing before much inconvenience is produced. In the small round-cell tumors and in some of the spindle- and mixed-cell varieties, the growth is 764 DISEASES OF BONE exceedingly rapid. The occurrence of a progressively growing tumor of a long bone without fever, or serious impairment of the function of the limb, is strongly suggestive of sarcoma. If aspiration fails to reveal the presence of pus, the probability of sarcoma is increased. If there is, in addition, the presence of the "egg-shell crackle," or an absence of joint-symptoms in tumors situated near an articulation, and if the .r-rays show the tumor to surround the shaft of the bone or to expand the cortical portion, the diagnosis may be said to be certain. In all doubtful cases, however, an exploratory incision and the removal of a section of the tumor for microscopic examination is indicated. Prognosis. — With the exception of myeloid or giant-cell sarcomata, the prognosis in malignant disease of bone is exceedingly grave. While McCosh has reported 3 out of. 7 cases of sarcoma of the femur, treated by hip-joint amputation, well from 4| to 12 years after operation, few such favorable statistics have been recorded. The majority of writers who have collected large series of cases, as Gross, Butlin, and Coley, state that the number of permanent cures is exceedingly small. In giant-cell sarcoma the outlook is comparatively favorable, as these tumors apparently do not give rise to metastases, and early and com- plete removal of the original focus will generally be followed by a permanent cure. Treatment. — The treatment of bone sarcoma depends largely on the nature of the growth. In all but the myeloid variety amputation should be practised sufficiently far above the disease, if situated in an extremity, to insure removal of the entire bone and surrounding tissues. Thus in sarcoma of the bones of the leg, amputation at the knee-joint or lower third of the thigh is to be advised. In disease of the lower extremity or shaft of the femur, the amputation should be at the hip-joint. In rapidly growing sarcoma of the upper extremity of the femur, operation is inadvisable. Sarcoma of the bones of the forearm should be treated by amputation just above the elbow-joint; those of the shaft and lower extremity of the humerus, at the shoulder- joint; those of the upper extremity of the humerus should be treated by removal of the entire shoulder-girdle. This has been the recognized practice in the past. Quite recently Cavaillon and Alamartine have advocated more limited operations, on the ground that in the great majority of instances the disease extends by direct prolongations from the original growth rather than by the carrying of fragments to distant parts of the bone by the circulating fluids. In support of this view they quote a large series of cases observed for a number of years in which a greater num- ber of three-year cures were obtained by the less mutilating operations. The subject is deserving of further study. If the tumor is of the myeloid variety, all surgeons now agree that amputation is unneces- sary, the disease being thoroughly removed by the sharp bone curet or lay partial resection. W T hen curettage is employed, every vestige of the tumor should be removed, the cavity should then be swabbed TUMORS OF BONE 765 with pure carbolic acid, douched with alcohol, and tightly packed with gauze to avoid hemorrhage, which is often free and difficult to control; or if bleeding is not troublesome, the cavity may be filled with Mosetig-Moorhof bone plug. In myeloid sarcoma of the lower jaw a bridge of bony tissue should always be left to prevent deformity. Inoperable, recurrent, and secondary sarcoma of bone may be treated by the Coley fluid or the mixed toxins of Streptococcus ery- sipelatis and Bacillus prodigiosus, the aj-rays or radium. There is of late a growing tendency among surgeons, even in the operative cases, to resort to the use of Coley's toxins immediately after operation. The results which have followed this method of treatment, as recently reported by Coley, certainly show an improve- ment over the treatment by operation alone. 1 Multiple Myeloma.— A disease characterized by multiple myeloid tumors in different bones of the skeleton, always associated with the presence of albuminose in the urine The disease as a rule occurs late in life, and affects by preference, the skull, vertebra?, or ribs. The tumors rarely grow to a large size, but occasionally give rise to press- ure symptoms, particularly of the brain and spinal cord. Another symptom produced by this disease is an abnormal fragility of the affected bone, often resulting in spontaneous fracture. As one cannot hope to remove all of the diseased areas, the only treatment at present advised is to remove those tumors producing pressure symptoms. Carcinoma. — Carcinoma of bone occurs only as a secondary deposit. As its occurrence under these circumstances is an evidence of general infection, no treatment is advisable. 1 Coley, Surgery, Gynecology and Obstetrics, February, 1908. CHAPTER XXVIII. INJURIES AND DISEASES OF JOINTS. Contusions. — Contusions in the neighborhood of joints are of fre- quent occurrence from all manner of traumata. They are accom- panied by superficial ecchymoses, occasionally by deep extravasation or hemorrhage into the synovial sacs. In the superficial joints, as the knee, elbow, wrist, and ankle, the injuring force may be so directed as to cause a bruising of the synovial membrane, which gives rise to an acute and often sickening pain, which soon disappears unless the trauma causes injury to the ligaments or tendons or results in synovitis. In the majority of cases no treatment is required other than temporary rest of the articulation and the application of a firm bandage. Sprains. — The term sprain is used to include a class of injuries somewhat similar in character to the preceding, but in which there occurs in addition, a rupture or at least a severe stretching of the ligamentous structures, muscles, or tendons which support the joint. These injuries in the majority of instances are produced by a severe wrench or twist of the articulation, which if continued would result in dislocation or fracture. The ankle and wrist, on account of their frequent exposure to such injuries, are the joints most likely to be the seat of sprain. After these injuries there is usually a rapid swelling of the tissues in the neighborhood of the joint, due to effusion of blood from the torn vessels into the extra-articular structures and often into the joint cavity as well. This is followed later by a non- infectious inflammatory reaction, which results in an exudation in the subcutaneous cellular tissue, muscles, tendon sheaths, ligaments, and synovial membrane, and not infrequently in the synovial sac. Symptoms. — The symptoms of a sprain are acute pain experienced at the moment of injury, which may be so severe as to preclude the possibility of using the extremity for several hours or days. In other cases the pain subsides after a few moments, but reappears on any attempt to move the joint or use the extremity. The joint appears swollen and is tender to touch, the points of maximum tenderness corresponding to the location of the ruptures of the periarticular tissues or to the subsequently developed hematomata. As soon as the reactionary inflammation appears there are heat in the joint, increased tumefaction, often redness, and a greater amount of tenderness and pain on motion. Ecchymoses appear and fluctuation often may be appreciated. SPRAINS 767 These symptoms may continue for a variable period, depending on the extent of the original injury or the treatment received. In a certain number of cases, even under the most approved methods of treatment, persistent pain on motion and areas of tenderness will remain long after the swelling has entirely subsided. In these cases there is generally present either an unrecognized fracture, a subacute synovitis, or, in the case of the ankle, a breaking down of the arch of the foot, with muscular spasm. Treatment. — When possible, immerse the injured part in a pail of hot water, and then gradually add hotter water until the temperature is as high as the patient can bear. The joint should then be bandaged as tightly as possible without causing pain — a rubber or flannel bandage being used. The first effect of the heat is to diminish the pain and to contract the vessels, thereby limiting the hemorrhage and serous effusion. The use of the elastic bandage applied immediately after Fig. 356. — A method of applying adhesive plaster strapping for sprain of the ankle. (Whitman.) the removal of the limb from the hot water serves to prevent subse- quent congestion and exudation. If the injury has been slight the joint may be supported by an adhesive plaster dressing (Fig. 356), and the patient allowed cautiously to use it. If the injury is severe, absolute rest of the joint should be advised, and. if comfortable, the bandage should be allowed to remain in place for two or three days. When the first bandage is removed the joint should be strapped with adhesive plaster. This prevents swelling and gives sufficient support to the parts to enable the patient to use the limb moderately without discomfort. In the majority of instances, however, the surgeon is not called until inflammatory reaction has appeared and the joint is in a condi- tion of acute hyperemia and edema. In these cases, rest in bed with hot fomentations or wet dressings of aluminium acetate is to be recom- mended for a few days until the inflammatory symptoms have disap- 768 INJURIES AND DISEASES OF JOINTS peared, after which a light plaster cast may be applied and the patient a lowed to go about on crutches. From the first, there should be continued effort to increase the circulation about and in the joint by local heat (baking, electric light, high frequency currents, hot water) and by active massage. In all cases of sprain, especially those occurring at the ankle or wrist, great care should be exercised by the surgeon positively to exclude the presence of fracture by means of an x-ray photograph, for no mistake is more easily made or more harshly criti- cised. If necessary, the joint should be examined under general anesthesia. Penetrating Wounds of the Joints. — These accidents are rare except as a result of severe traumata, gunshot or stab-wounds. While the smaller joints occasionally may be opened and the untoward results be limited to a slow process of healing, and perhaps a permanent ankylosis, wounds of the large joints are often followed by loss of the limb or the life of the patient. This is particularly true of the knee- joint, the synovial membrane of which is justly regarded by sur- geons as one of the most vulnerable tissues of the body to septic infec- tion, and, on account of its peculiar shape and anatomic relations, is of all the joints the one most difficult to drain and successfully to disinfect. - Moreover, there seems to be in the synovial membranes of the larger joints less protective power, and a greater amount of septic absorption than from any other tissue of equal size and vascu- larity. From what has been said, it wil appear that the danger of these injuries is solely from infection and the treatment, therefore, should consist in measures to prevent or combat it. Symptoms. — The symptoms of a penetrating wound of a joint are, in addition to the visible signs of a wound which might open the synovial cavity, the presence of a flow of synovia from the cutaneous opening. This is a clear, syrupy fluid, which is fairly abundant from the large joints, and may be tinged with blood. A similar fluid may appear in such a wound from an injured extra-articular bursa, but in these cases the fluid is, as a rule, less abundant. Inspection will occasionally reveal the presence of the exposed glistening white articular cartilage in the bottom of the wound. Pressure over the uninjured portions of the joint sac will sometimes result in the appear- ance in the wound of an increased amount of fluid blood or synovia. Any injury to the joint capsule small enough to need the aid of a probe for diagnosis is better treated expectantly because of the improbability of a probe remaining uncontaminated during its passage from the skin to the joint. Treatment. — In all cases of suspected wound of a joint an antiseptic dressing immediately should be applied and the patient removed to some place where an aseptic examination can be made. If the con- ditions are such that an aseptic exploration cannot be carried out, it is wiser to allow the wound to heal as quickly as possible under the primary dressing, in the hope that infection has not occurred, or that Fl.o AT l\c CARTILAGE IN THE JOINT 769 the resistance of the individual is sufficient to cope with it without assistance, and to inter ere only in case evidences of sepsis appear. In addition to the primary dressing, the limb should be immobilized, and the patient placed in bed. The bowels should be freely moved, and diuresis favored by copious draughts of pure water to assist in elimi- nation of any toxins that may develop. If evidences of septic arthritis appear, the joint should be treated in a manner presently to be described. If the conditions are such as to insure an aseptic examina- tion of the wound, the surgeon should first pack the external wound with sterile gauze, then scrub and shave the neighboring parts, after which the packing should be removed and the cutaneous wound cleansed thoroughly with soap and water followed by prolonged irrigation with hot saline solution. In injuries caused by oily bodies such as machinery, a* preliminary scrubbing with benzine will remove much of the gross material. Tincture of iodin copiously applied to a lacerated wound has a wide vogue among railway surgeons. If the wound is found to penetrate the joint cavity with slight injury to the capsule and intra-articular structures it should be sufficiently enlarged to allow thorough irrigation of the sac with sterile salt solution. The wound should then be closed with superficial drainage and a bulky aseptic dressing applied. With only slight laceration of the joint structure, the overlying tissues may be loosely sutured with- out drainage. If the tissue destruction is very great and infection positive, a rubber tube drain is sutured securely to the skin so that its deep end reaches but does not penetrate the joint cavity. Following this the most careful watch is kept for evidence of suppuration in the joint which is then appropriately treated. It is only by these non- interfering procedures that healing of the joint may be hoped for without ankylosis, for here as in injuries to the tendon sheaths, large drains not only abrade the joint surfaces but serve as ready guides for bacteria invading from the skin. If the wound remains aseptic the dressing should not be changed for a week or ten days. Floating Cartilage in the Joint. — Free cartilaginous masses are occasionally encountered in the larger joints, especially the knee. They represent either small fragments broken off from the articular surfaces by traumata, or, more commonly, chondrified portions of the synovial folds or fringes which have become detached by the move- ments of the articulation. Symptoms. — When these movable bodies are caught between the articular surfaces of the bones they give rise to a sudden acute pain, with "locking of the joint." The patient often falls to the ground and is unable to move the limb. Forcible flexion and extension will sometimes cause the symptoms to disappear. Careful palpation will generally reveal the presence of the cartilage. Treatment. — The treatment should consist in aseptic incision and removal of the foreign body. The joint, however, should never be 49 770 INJURIES AND DISEASES OF JOINTS opened for this purpose unless the cartilage is distinctly felt and held by the fingers of the surgeon, for extensive exploration of the joint cavity is often unsuccessful and accompanied by grave risk of infection. Dislocation and Injury to the Semilunar Cartilage of the knee joint may produce similar symptoms, and is described on page 903. For fractures entering the joint and dislocations see chapters on Fractures and Dislocations, pages 806 and 873. Inflammation of Joints. — In considering joint inflammations it is well to remember that the structures entering into the formation of a joint are composed of tissues originating in the same mesodermal layer, and capable of transformation from one connective tissue form to another through metaplasia, so that synovial membrane may become cartilage or bone, and bone be transformed into fibrillary connective tissue, etc. The bones near the joint contain the growing centres and numerous blind end vessels. The cartilage is avascular and almost incapable of repair or of any immunizing activity, and is the first tissue to be destroyed by infection. The synovial membrane is composed of flattened connective tissue cells rich in intercellular substance. The synovial fluid is a liquefied intercellular substance and not a secretion. The blood supply of the synovial membrane is poorly connected with that of the periarticular tissues; the vessels in the joint fringes have a coiled appearance making them act more or less as closed end vessels. The synovial lymphatics have no lymph stomata as in other closed cavities, which perhaps explains the fact that joints seldom share in general anasarca, and the difficulty with which joint effusions are absorbed. Nerves are numerous in the synovial membrane but absent in the cartilage. In the normal functional activity of a joint, there is constantly a certain amount of trauma incident to exercise, so that in health the joint is in a state of balance between irritation of the joint structures and the reparative or adaptive power of the tissues; but when the range of normal tolerance is passed by the trauma, or foreign irritating substances are introduced as bacteria or toxic agents, or when the adaptive powers of the body or of the joint become lowered as by exposure or disease, the balance becomes disturbed and abnormal adaptive processes occur which we call inflammation. Etiology. — The chief exciting etiological factors in joint inflammation are mechanical trauma, chemical agents or bacteria, acting on a joint with normal or lowered resistance. Mechanical irritation may be caused by accidental trauma; by excessive exercise, as in forced marches where examination of the joint fluid has revealed the characteristics of an exudate; by static changes with bearing of the weight by improper surfaces; by loose foreign bodies, hypertrophied synovial fringes, osteophytes, movable joint cartilages; and possibly by crystals of uric acid. Chemical irritation may be caused by homogentisic acid, uric acid, lead, decomposition products as in hemarthrosis, and toxins from INFLAMMATION OF JOINTS 771 the intestine or from other bacterial foci, as in the so-called tuber- culous pseudorheumatism of Poncet, in which toxins from a distant tuberculous focus are believed to cause an acute arthritis. Of the bacterial irritants, there may be mentioned the streptococcus, staphylococcus, gonococcus, pneumococcus, and many other varieties of pathogenic micro-organisms. Many of these have been recovered from inflamed joints, as well as from the anatomically related lymph nodes. Rosenow has recently shown that practically all varieties of acute and chronic arthritis may be produced by direct infection of a joint by the various strains of the streptococcus. In his interesting experimental work, he has shown that by cultural changes or by passing a given organism through animals, he can effect marked mor- phological and cultural alterations; changing streptococci of one variety into another, 'and again into pneumococci or into intermediate forms such as the micrococcus of Poynton and Paine, found in acute articular rheumatism. Experimentally it has been found that the same organism, because of these variations, may cause in joints, inflam- mations from the most acute and fatal, to those of mild and persistent course. Often one injection will cause in the same animal several varieties of arthritis. All bacteria do not cause joint inflammation, but only those which have a special affinity for joint tissues. The Streptococcus viridans which may cause severe heart lesions without injuring the joints, when it has been converted by mutation into a Streptococcus hemo- lyticus causes the reverse to occur. The three types of causes mentioned above may act singly or in combination, as in those joints which becomes infected with the added element of trauma or gout. The second factor in joint inflammation is the adaptive power of the joints. In old age the joint becomes worn out, it no longer cares for the trauma which in youth it could resist. The same thing occurs in younger individuals when the joint is deprived of its nerve supply or otherwise weakened as by exposure, acute disease, etc. The source of chemical irritants is variable, toxins may arise from the intestines, from a tuberculous or septic focus, from errors in diet, or from metabolic disturbance as in gout. Of the bacteria; the streptococcus in the majority of instances is derived from the faucial tonsil, from pyorrhea alveolaris, from the nasal cavity or accessory sinuses and from the seminal vesicles where they may be found long after the disappearance of the gonococcus. The gonococcus in males is found most frequently in the prostate and seminal vesicles, in women in the uterine tubes and cervical canal, rarely in an old Bartholinian abscess. The staphylococcus comes usually from some acute focus as a folliculitis or osteomyelitis. The pneumococcus is found less frequently after pneumonia than otherwise. Pathology. — The pathologic changes in an inflamed joint vary with the type of the inflammation and the acuteness or chronicity of the 772 INJURIES AND DISEASES OF JOINTS process. These together with the symptomatology and treatment will be considered later with a description of the various clinical types. Arthritis. — The classification of arthritis is still in the formative stage. Assuming that the etiological classification is the most desir- able this will be given as far as possible, and other clinical types of uncertain etiology mentioned under their clinical titles. The division into acute and chronic is convenient for classification and will be used, but it must be remembered that there is an unbroken gradation from the most acute arthritis to the mildest chronic joint disease, so that the terms indicate extreme grades of the same process. Acute Arthritis. — Acute arthritis may arise from trauma, bacteria or chemical poisons or toxins. Acute Traumatic Arthritis (serous synovitis) may be caused by a blow or wrench of the joint, with injury to ligaments and cartilage; by hemorrhage into the joint; and by foreign bodies. There is injury to the tissues varying with the site and degree of the trauma, also an exudate of serum, blood, small amounts of fibrin and later some leuko- cytes. The joint cavity is distended and the ligaments somewhat loosened. The process usually terminates in resolution, but if the cause persists, it may become chronic. Symptoms. — The symptoms are sudden sharp pain, later becoming dull, constant, and always increased by motion: swelling, reaching its maximum in about forty-eight hours; tenderness, moderate heat and, rarely, redness of the skin. The swelling obliterates the normal out- lines of the joint, gives rise to fluctuation and causes the joint to be held in a position to allow the greatest distension of the capsule. Signs of effusion into the larger joints. In the shoulder-joint there is general swelling in the region of the articulation which lifts the deltoid muscle and may be felt in the axilla. It is distinguished from the swelling due to inflammation of the subdeltoid bursa by the fact that in the latter condition the bursal swelling is in the space beneath the centre of the muscle and cannot be felt in the axilla, whereas in joint effusion the swelling extends to or beyond the anterior and posterior borders of the muscle and is especially noticeable along the bicipital groove. In the elbow-joint an effusion causes a bulging posteriorly on either side of the olecranon and triceps tendon. Inflam- mation of the olecranon bursa gives rise to a swelling over the olec- ranon. In the wrist-joint there is general tumefaction anteriorly and posteriorly, which lifts the tendons and is sharply limited above and below by the radiocarpal and carpometacarpal joints. Inflammation of the common flexor tendons bursa causes an hour-glass swelling on the flexor side of the wrist above and below the annular ligament. Effusion into the hip-joint causes a fulness about the joint which is most noticeable in the post-trochanteric region and in the region of Scarpa's triangle. The limb is partly flexed, abducted and rotated out- ward. Iliofemoral bursitis causes a swelling on the inner aspect of the thigh only, and in gluteal bursitis the swelling is limited to the buttock. ACUTE INFECTIVE ARTHRITIS 773 In the knee-joint the effusion causes obliteration of the normal depres- sions on either side of the patella and its tendon. The swelling is especially marked above the patella as an oval fluctuating tumor which may extend upward for two or more inches and in children to the middle of the thigh. The patella floats hut may he made to click against the condyles by quick firm pressure. These signs are absent in prepatellar bursitis in which case the fluctuating swelling lies anterior to and below the patella. In pretibial bursitis the swelling bulges the space on either side of the patellar tendon and is triangular in shape with the base directed upward, and the apex pointing to the tubercle of the tibia. In the ankle-joint the effusion bulges and effaces the normal depressions between the malleoli and the tendo Achilles. The flexor tendons are raised from the bone and fluctuation generally can be detected. Treatment. — Treatment is purely local; rest on a splint with hot or cold applications; later massage, moderate use, hydrotherapy and pressure to the joint by a bandage, or by adhesive plaster. If the effusion is severe or persistent, aspiration by a trocar and cannula under strict asepsis is indicated. The prognosis depends on the etiological factor and should be guarded until intra-articular derangement can be excluded. In most instances recovery follows the employment of the measures outlined above. If, however, the joint after injury is still further irritated by functional use, the condition may become chronic. This will be described later in the chapter under Chronic Serous Synovitis. Acute Infective Arthritis. — Etiology. — Acute, infective arthritis occurs as a result of a penetrating wound or by infection reaching the joint through the blood or lymph currents. Nearly all the bacteria mentioned above have been found in acute septic arthritis. Pre- disposing causes are trauma and general depression of health. While it may be true that the toxins of bacteria coming from other foci may cause inflammation, yet the increasing frequency with which bacteria are isolated from these joints tend to lessen the number of such cases. Pathology. — The pathology is that of any acute inflammation, congestion, exudation of serum, fibrin (dry septic) and pus, with necro- sis, either microscopic or gross, of all tissues affected. The process begins in the subchondral bone or rarely in the synovial membrane, and is due to the lodgement in these structures of bacteria carried in the circulation from some primary focus. The process spreads to the other joint structures and may progress until it destroys the joint or the life of the individual; or, resolution may take place with complete restoration of function, repair by granulation tissue, fibrous, cartilag- inous or bony ankylosis. In rare instances the process may continue as a chronic infective arthritis. Symptoms. — The onset is sudden or may extend over several days, and is often masked by the primary infective process. Febrile symp- toms often with chill usually precede the pain. This in turn, especially 774 INJURIES AND DISEASES OF JOINTS when the focus is in the bone at some distance from the joint surface, may precede any signs in the joint. When the joint becomes involved, there is limitation of motion by muscular spasm, the joint being held in the position to give the greatest volume to the joint cavity, swelling with fluctuation, heat, redness, great tenderness and pain of dull, severe, continuous character, made excruciating by any movement. With resolution, which may occur at any time, and at any stage of the process, the symptoms subside, the joint remains moderately stiff for several weeks and eventually recovers more or less complete func- tion. If the process advances, the pus bursts through the capsule, gives rise to a periarticular cellulitis, and may rupture externally. Death exceptionally may occur before there are any marked signs in the joint. Clinical Varieties. — The clinical and pathological picture varies somewhat with the different organisms. The Streptococcus hemoliticus causes a virulent monarticular, less often polyarticular arthritis, either causing death by sepsis before there is much more than a seropurulent exudate, or goes on to great destruction of cartilage. It rarely affects the heart. The Streptococcus viridans causes more often a polyarthritis with less exudation in the joint but considerable infiltration of the peri- articular structures, tendonous insertions and flat muscles, and more frequently involves the heart. The diplococcus rheumaticus (Poynton and Paine) is said to cause the polyarthritis of acute rheumatic fever, with feeding of infection from joint to joint, periarticular rather than intra-articular infiltra- tion and severe heart involvement. Rosenow believes that this may be a mutation form of streptococcus. The pneumococcus causes usually a monarticular lesion, affects the large joints, especially the shoulder, where there is an exudate of thin yellow pus with mild or severe injury to the joint. It usually, but not always, follows pulmonary inflammation. There are many other varieties of streptococcus causing arthritis, but their differentiation is as yet imperfect. It may be that they are, as Rosenow believes, all forms of the same organism with virulence, and morphological and cultural characteristics changed by their growth in the body and producing all types of arthritis depending upon these factors. Staphylococcus arthritis is not common, is usually one of a number of pyemic foci; the course may be very chronic and the numerous foci develop at considerable intervals. Gonorrheal arthritis occurs rarely during the acute stages of the primary disease but may occur at any time during its existence, especially after involvement of the prostate, seminal vesicles, Bartho- lin's gland, cervix and Fallopian tubes. The clinical picture varies from an acute polyarthritis, indistinguishable from acute rheumatic fever, to a chronic monarthritis with slight persistent effusion and ACUTE INFECTIVE ARTHRITIS 775 stiffness. Usually there is an acute polyarthritis of moderate degree with final localization in one joint, which becomes a characteristic chronic infective arthritis, with changes most marked in the periarticu- lar structures. Rarely there is a chronic progressive polyarthritis, distinguished from the other usual forms only by the isolation of the organism or the complement fixation test. There is a chronic poly- arthritis appearing long after the gonococcus has disappeared from the body and is probably due to persistence of organisms secondary to the gonococcus in the prostate or seminal vesicles. The acute joint infections, caused by the colon bacillus and typhoid bacillus, are usually monarticular and secondary to bone involvement. Treatment. — In the treatment of acute infectious arthritis, one should remember that in every instance in which the symptoms are ushered in by a definite chill,.destruction of tissue leading to obstinate or perma- nent ankylosis will follow unless the intra-articular tension is speedily relieved by extension, aspiration, or arthrotomy. In the milder cases without marked or progressive toxemia, removal of the exudate by aspiration, followed by irrigation with sterile salt solution and the injection of 10 to 30 cm. of an antiseptic fluid, is to be recommended. This should be repeated as often as the joint fills, usually every second or third day. At each aspiration all of the infected fluid should be evacuated. Of the antiseptic agents, 0.5 per cent, phenol in water or 1 per cent, formalin in glycerin are the most useful. Often from six to ten treatments are necessary to bring about a cure. The results of this treatment often are strikingly satisfactory, as complete res- toration of function is the rule in favorable cases. In cases of infec- tious arthritis following a penetrating wound, and in all cases with rapidly advancing toxemia, arthrotomy, thorough irrigation and drainage are to be advised. This is best accomplished by making several incisions, and draining with rubber tubes introduced to but not within the synovial cavity. In the severest cases threatening life, the Mayo operation is indi- cated. This operation, which originally was performed on the knee joint, consists in a semilunar incision from one condyle to the other across the front of the joint through the patellar tendon. When the joint is freely opened by this method, the leg is acutely flexed, the crucial ligaments severed, and the capsule sufficiently divided to expose freely every recess of the synovial membrane. The parts are then thoroughly cleansed, the leg fixed in the flexed position by suit- able apparatus, and the exposed joint surfaces packed with wet bichloride or formalin gauze. Improvement in the general septic symptoms almost invariably follows this procedure if carried out before a blood infection has occurred, but many weeks are sometimes required before all evidences of sepsis have subsided. After con- valescence from the infection is thoroughly established, the ends of the bones should be excised or all necrosed portions of the cartilage removed, the leg extended and firmly fixed by a posterior splint or 770 INJURIES AND DISEASES OF JOINTS plaster cast. The skin flaps can be easily approximated after excision of the bones, and should be held together with two or three sutures, the rest of the wound being left freely open for drainage. Bony union eventually takes place, and a useful but stiff limb will result. As soon as the tension in the joint is relieved, or where the process is mild or polyarticular in type, as in the so-ealled acute rheumatic fever, an effort should be made to locate and remove the source of infection, as a diseased tonsil, furuncle, alveolar abscess or Rigg's disease; and certain arthrotropic drugs as the salicylate of sodium may be employed. Efforts should be made to increase the resistance of the individual by good food, fresh air and other hygienic measures; elimination of the toxins favored by catharsis, and an abundance of drinking water. Much may be expected by the judicious employment of autogenous vaccines, and occasional benefit is derived from the use of antistreptococcus, antigonococcus and other sera. These measures should be continued with local rest, hot or cold applications and separation of the joint surfaces by position or traction. As the process subsides, massage, passive motion, hot. and cold douches and electricity will be indicated to restore motion and increase the nutrition of the muscles. Gouty Arthritis. — Gouty arthritis is the clearest example of chemical irritation of a joint, although toxins from various sources as men- tioned above may be excitants. True gout attacks by preference the metatarsophalangeal joint of the great toe and the joints of the hand, rarely the knees, elbows or the other large joints. It is a manifestation of a general disease of metabolism characterized by the deposit periodically of sodium biurate crystals in cartilage and certain connective tissues. In the joint this gives rise to an acute inflammation with effusion, and later cup-shaped ulcerations of the cartilage, thickening of the peri- articular structures, moderate bone formation, and fibrous or bony ankylosis. The diagnosis is established by the determination of errors in uric acid metabolism, tophi in the lobes of the ears and by the peculiar acute insinuating pain coming on at night. The treatment is purely medical, with drugs, baking, hydrotherapy and massage. Chronic Arthritis. — The classification of chronic arthritis is also in the formative stage. Assuming that the most important factor in the treatment is the removal of the cause, we will, as far as possible, adopt an etiological classification, present the cases as they come under this heading and then follow with several clinical types in which the etiology is very obscure. Secondary infective arthritis describes those cases which are merely the terminal stage of an acute septic arthritis. Chronic Primary Progressive Polyarthritis is the name given by Barker to include all of those cases with a supposedly infectious origin, characterized by a primary chronic progressive course of mild inflammation in the joints. The name distinguishes it from secondary infection arthritis merelv in that the chronic character of the disease is primary and CHRONIC ARTHRITIS 111 has not followed a previous severe infection of the joint, although as in acute arthritis, the lesion is probably secondary to an infections focus elsewhere in the body. It. is meant to include those conditions which have been given the name arthritis deformans, rheumatoid arthritis-, chronic rheumatism, hypertrophic osteo-arthritis, arthritis ankylopoitica, and Still's disease. Etiology. — The etiologic factor in these cases, is a mild chronic irritation of the joint structures. The bacteria which were mentioned under general considerations of the subject have all been found in chronic joint disease. Of these the streptococcus is the most interesting and important, and has been isolated in its various cultural and morpho- logical varieties. In a series of joints in which no organism could be isolated, Hastings found that 40 per cent, gave a complement fixation test of streptococcus -viridans. Experimentally the strains of strep- tococcus have been made to cause all grades of arthritis by one injec- tion. A streptococcus isolated from a case of polyarthritis in the human patient, injected intravenously into a rabbit, caused poly- arthritis similar to that in the human and was recovered in pure culture from the joints (Billings). Other irritating factors are the mechanical irritations due to changes in the posture of the patient with alteration of the weight bearing surfaces, and secondly by subsequent intra-articular inflammatory growths. Chemical irritation is proven frequently by alteration in the uric acid metabolism of the body, indeed gout is considered by many to be one of the most important predisposing causes to the localization of the infection, even though severe gouty symptoms may be absent. The second factor in joint inflammation is the adaptive power of the articular structures. An organism which might be destroyed even though it arrived in the joint structure, would in one of altered adaptive powers, cause inflammation. It is for that reason that exposure to cold and wet, severe muscle strain, bad habits of eating, constipation, intestinal fermentation, often decay of the teeth, or other chronic infections from w T hich the joint organism can be excluded, become important predisposing factors to the activities of the actual infecting organism. The portal of entrance of the bacteria in the majority of cases, is the faucial tonsil, next disease of the teeth, thirdly, disease of the genito-urinary tract, and fourthly, the sinuses of the nose. Pathology. — The initial lesion is either in the subchondrial trabecu- lated bone, or in the synovial sheath or fibro-areolar cartilage, where there is an initial necrosis followed by the exagerated processes of repair. This develops into two pathological types. In the first the exudative and granulation tissue formations predominate, in the second the production of scar tissue without marked hyperplasia, In the first there is early separation of the cartilage by the subchondral inflammation, necrosis, fibrillation, separation of large and small fragments with baring of the ends of the bone which through pressure 778 INJURIES AND DISEASES OF JOINTS become eburnated. The bones become covered with granulation tissue and show lipping at the edges of the cartilages and formation of bony osteophytes which break off and become loose bodies. There is moderate exudation. The joints may become distended with fluid and with the shaggy synovial proliferation, the capsule becomes stretched, and various degrees of dislocation occur as a result of mus- cular traction. In the second form, along with mild destructive processes, there is a great increase of connective tissue with only slight overgrowth of bone and synovia, so that the joint becomes stiff with fibrous and often later bony ankylosis. While these two pictures are distinct, it must be remembered that they represent only the extreme types and there may be all stages between. Microscopic examination of the joint structures show that there is little arteriosclerosis but great endothelial proliferation in the smaller vessels, possibly causing retar- dation of oxydation which favors the growth of the bacteria. Numer- ous lymphocytes are found in the subintimal layers of the blood- vessels. Bacteria occasionally are found in the joint fringes, peri- articular structures, bone, bloodvessels, and rarely in the joint fluid. Changes in the structures near the joint are, infiltration and atrophy of the muscular attachments; atrophic processes of the bone, first absorption with rarefaction and the formation of cysts, secondly a thinning of the cortex. These processes are more marked in the inflamed joints than in those simply suffering from the atrophy of disuse. There is a distinct myositis with productive inflammation, contraction and atrophy, affecting particularly the biceps humeri, masseter, erector spinse, the anterior tibial group and the hamstrings. These muscles are not necessarily associated with the involved joint. In addition there is usually a moderate degree of neuritis or perineuritis. The general pathology is that of a chronic infection, leukocytosis with a slight if any predominance of polymorphonuclear leukocytes, anemia, emaciation, trophic changes such as pigmented glossy skin, brittle nails and sweating of the palms. The lymph nodes are often involved, particularly those in the region of the infected joints, and occasionally the spleen. There is a very frequent alteration in the uric acid metabolism, although never as much as is found in true gout. Symptoms. — The onset is of two types, one fairly acute, extending over a few days or weeks, occurring in young women, rarely at the menopause, less frequently in males, with rapid serial involvement of many joints, considerable pain, slight rise in temperature and other symptoms of a moderate infection. The second is very gradual, extending over months and years, occurring in old people, in women particularly at the time of the menopause. The small joints of the hand are first involved with slight stiffness, little pain, and only become generalized as in the first type after many months or years. When fully manifest the two types vary only in severity. The joints CHRONIC ARTHRITIS 779 involved are, in order, those of the fingers, hands, knees, feet, ankle, wrist, temporomaxillary, shoulders, elbows, and hip. The involvement is usually symmetrical. The symptoms may jump from one joint to another somewhat as in acute rheumatic fever. The pain is referred to the joints involved, also to muscles affecting these joints, or even isolated. Sometimes pain will appear especially in the shoulder joint long before the physical signs in the joint can be made out; neuralgic twinges are common. The character of the pain is dull, continuous while at rest with acute exacerbation. It occurs with the lowering of the general condition by exposure to cold and damp, insufficient food, constipation, intestinal fermentation, or intercurrent infection. It is relieved by measures directed against the inflammation, rest, passive congestion and rarely by salicylates. Fig. 357. — Arthritis deformans. (Musser.) It is made worse by any motion and unaffected by the time of day. Voluntary movement gradually becomes impossible. The general condition is that of- any chronic infection. Loss of flesh, strength, pallor, headache, drowsiness, etc. On examination the joints vary somewhat, as mentioned in the pathology. In the hypertrophic joint the skin has a shiny, bluish color with prominent veins, the size of the joint is considerably increased. The joint is swollen, globular, fusiform or spindle-shaped, with irregularities due to bony enlargement and distension by villous masses. There may be a slight increase in synovial fluid, giving fluctuation, more often a crunching sensation. The extremities are held in a position to allow the greatest distension of the joints, at first in semiflexion, later become extended with the occurrence of luxation. In the milder grades there is ulnar deviation of the fingers due to the bony changes at the bases of the phalanges (Fig. 357). The mobility is limited at first by pain, then by exudation, later by the intra-articular 780 INJURIES AND DISEASES OF JOINTS deformities and muscular contractions. Sometimes it is increased in an abnormal direction because of the loose capsule. On palpating the joint there is a crunching sensation of the villi, often crepitus due to loose bodies which often can be freely moved about. In the sclerotic variety the skin has a more normal appearance, the joint is normal in size, or lightly increased, the bony landmarks are only slightly obscured and they are in their normal relationship. The joint may be held in slight flexion or ridgedly straight. The deformities of the fingers are the same as those previously mentioned. Movement is at first decreased by pain, later by adhesions, anky- losis and thickening of the capsule. On moving the joints there is a creaking sensation rather than a crepitus. In both joints the .r-rays show periarticular swelling, atrophy of the cartilage, erosions of the subchondral bone, rarefaction of the spongy portion, the formation of cysts, thinning of the cortex, subperiosteal swelling, calcification and ossification of the ligaments. In the hyper- trophic form there are various luxations, pathological deviations, dis- tortion in the shape of a bone with osteophytes and exostoses, and calcification of free bodies. In the sclerotic form there is narrowing of the joint slits, fibrous and bony ankylosis. This narrowing of the joint slits can be determined by attempting to inject the joint with oxygen, but this rather questionable procedure is rarely necessary to establish the diagnosis, and is not to be recommended. General physical examination may or may not reveal the primary focus, and shows the picture of chronic infection with enlargement of the lymph nodes, occasionally of the spleen and the blood picture of infection with marked anemia. Examination of the metabolism of the body shows a slight modification of the uric acid metabolism and disturbance of the nitrogen balance. The course of the disease is essentially chronic and progressive, more joints become involved, the patient becomes bedridden, the joints practically become immovable, the patient finally dies with the appearance of chronic sepsis. Treatment. — Treatment should be undertaken in an institution with facilities for specialized investigation for all parts of the body. The genera] plan of treatment is to remove the cause if possible, to raise the general resistance of the patient,, and secondly the local management of the joint. The cause is removed, after a careful search of all possible foci of bacteria by specially qualified men, by surgical means. If none are found after this extensive search, the tonsils are removed on sus- picion, in as much as they have been found to be a source of bacteria in over half the cases (Billings). From the tissues removed the offend- ing organism is isolated if possible and from it an autogenous vaccine prepared. Mechanical factors such as faulty posture, and deformities as flat foot or genu valgum are given appropriate orthopedic treatment. Foreign irritating bodies occasionally may be removed surgically from the joint. STILL'S DISEASE 781 The general treatment is to raise the general body tone, to bring about a normal metabolic- balance and to arouse the specific immunity against the offending organism. General body tone is raised by tonic treatment with fresh air, sunlight and cheerful environment, and the use of arsenic, cod-liver oil and butter fat. Metabolism is investigated and a diet proper for the individual is planned, usually a full, mixed diet but with scant proteids. Elimination by regular bowel move- ments and the drinking of large amounts of water is fostered, with moderate physical rest sufficient to relieve the joints but not to cause atrophy. Glandular therapy such as thymus and thyroid have been given empirically with possibly good results. Fermentation in the intestinal canal is combatted with large amounts of lactic acid milk. To raise the general specific immunity against the organism, auto- genous vaccines are employed; made from the joint tissues, the exudate from adjacent lymph nodes, and from cultures made from primary foci as carious tooth sockets or tonsils. Antistreptococcus serum has been used, but danger from anaphylaxis should prohibit it. Local Treatment. — Consists of rest for the joint by the recumbent position or, rarely, by cast or apparatus. The local resistance of the joint is aroused by increasing the blood and lymph supply by active congestion with the agency of heat to the skin, such as baking, hot water, electric light, and other methods; by applying heat to the interior of the joint by the D'Arsoval current, passive congestion after Bier, and by massage judiciously applied. Radioactive agents such as the ultra-violet rays, direct sunlight, x-rays, high-frequency current besides the heating effects are supposed to produce good results, but their method of action is as yet unknown. Irritation of the interior of the joint by carbolic acid, formalin and iodine in glycerine is supposed to excite the structures to better resis- tance. The products of inflammation are removed by compression of the joint which mechanically forces the fluid to the surrounding tissues, and by aspiration. Masses of granulation tissue, bony or cartilaginous growths and hypertrophied joint fringes are sometimes removed by arthrotomy. Deformity should be prevented as far as possible by active and passive motion, as soon as the subsidence of the infective process will permit, or later is corrected by forcible reduction by the application of corrective apparatus, or by open arthrotomy with anthroplasty, arthrolysis or simple arthrotomy with correction of the deformity. Still's Disease. — Still's disease is a chronic progressive polyarthritis similar to the above, with rather marked febrile symptoms occurring in children usually under ten years of age, characterized by severe anemia, leukocytosis, and definite involvement of the lymph glands and often of the spleen. It is regarded by many as a juvenile form of the above condition. 782 INJURIES AND DISEASES OF JOINTS Chronic Primary Hypertrophic Arthritis (Chronic Ulcerative Arthri- tis, Senile Arthritis, Morbus Coxae Senilis). — Is a disease of advanced life, involves one or few joints, usually the larger, especially the hip, shoulder, knee and spine; it is asymmetrical and causes little disturb- ance of the health. Its cause is presumed to be the failure of the ordinary reactive powers of the body to withstand the normal trauma incident to daily exercise, although the colon bacillus is said to have been found associated with this condition. The pathology shows no ankylosis. There is considerable lipping of the edges of the bone and cartilage and fibrillation of the cartilage in very old people. There is bony overgrowth with formation of osteo- phytes, and foreign bodies. There is ulceration of the cartilage with fibrillation and often exposure of the ends of the bone. The capsule is moderately contracted. The joint slits are preserved as may be seen by an a-ray plate. The symptoms are of a local condition having little effect on the general health, progressive but not disabling. On examination there is stiffness, grating of the joints and the finding of foreign bodies and inflammation of the ends of the bone. Treatment. — The treatment is by general tonic measures, with correction of static deformities, and attempts to improve the local resistance of the joint as mentioned in the above section. Chronic Villous Arthritis. — Chronic villous arthritis is a disease often found in athletes especially in the knees and is usually bilateral. It is characterized by shaggy formation of the synovial membrane covered by low cylindrical cuboidal flat connective-tissue cells. There is scant fatty formation in the supporting stroma. In these fringes are often found strips of cartilage formation. Its etiology is presumed to be mechanical irritation of the joint either through excessive pressure between the joint surfaces, or more fre- quently because of an increased leverage of motion, as is found in base-ball players and wrestlers. The treatment is a change of occupation, rest of the joint, massage, and an increase of the circulation by other means mentioned above; and if necessary by the surgical removal of the hypertrophied fringes. The Arthritis Deformans of Children (Perthes). This is a condition found in the hips of children in which there is a melting away of the head of the femur, very similar to the bony process in tuberculosis, but without the discovery of the tubercle bacillus in the lesion, or of the reaction to tuberculin. The etiology is unknown. The symptoms are a disturbance of the gait with little or no pain, deformity of the joint with adduction because of progressive trauma. The treatment is mechanical support by cast; the prognosis good. Syphilitic Arthritis. — Joint inflammation may develop as a lesion of hereditary syphilis, or as a secondary or tertiary symptom of the acquired disease. TUBERCULOSIS OF JOINTS 783 Hereditary joint syphilis is generally an osteochondritis, which may give rise to gummatous degeneration, separation of the epiphysis, and secondary involvement of the joint. The acquired disease may be accompanied by a serous synovitis in the secondary stage, or give rise in the tertiary period to a gummatous synovitis or epiphysitis which in its behavior closely resembles tuberculous joint disease. Arrest of the growth of bone may follow destruction of the epiphysis. Symptoms. — In the early secondary stage of acquired syphilis the joints may become painful and swollen from the presence of a serous effusion. This, however, quickly disappears under energetic mercurial treatment. In the tertiary period an effusion may also appear, which is generally due to the presence of some neighboring gummatous lesion in the bone or. soft parts. Syphilitic epiphysitis or osteochon- dritis in infants is characterized by enlargement and tenderness of the articular extremity of the bone. If the disease progresses, the joint may be invaded and the condition may closely resemble a tuber- culous arthritis. Occasionally it can be distinguished from the tuber- culous affection, however, by the absence of muscular rigidity and by the improvement often manifested as a result of antisyphilitic treat- ment. In the more severe cases rapid destruction of the joint occurs and suppuration may follow, or a painful and useless condition of the joint which has been described as syphilitic pseudoparalysis. In acquired syphilis the gummatous arthritis also resembles the tubercu- lous affection, and differential diagnosis may be impossible. The symptoms which would serve to distinguish a syphilitic from a tuber- culous arthritis are: the presence of spontaneous pain during rest at night, the absence of severe pain on motion or manipulation of the joint, the absence of muscular rigidity, and the fact that the tumefaction of the tissues and the synovial effusion if present, vary considerably in extent from time to time even without treatment. In most of the reported cases the knee-joint has been the one chiefly involved. Treatment. — Syphilitic joint disease should be treated by large doses of salvarsan and mercury in the secondary stage, with the addition of potassium iodide in the later stages. Tuberculosis of Joints. — Etiology. — The predisposing cause is that of tuberculosis in general. Ill health from improper nourishment and from disease such as measles and scarlet fever and possibly from family susceptibility. Contagion from a tuberculous environment, either by inhalation or through the food is by far the most important element. The exciting factor is the tubercle bacillus, usually the human type but occasionally the bovine. The portals of entrance are most often the intestinal mucosa, with subsequent caseation in the mesenteric lymph nodes and the liberation in the blood of the bacilli, which find their resting place in the end vessels of the epiphyseal or subchondral bone of the joints in the young, and in the lungs in adults. Other less frequent portals of entry are the lungs, the nose, the pharynx, faucial and lingual tonsils, the teeth and possibly directly through the 784 INJURIES AND DISEASES OF JOINTS skin. Tuberculosis is the most frequent cause of joint disease. It is commonest in children but may occur at any age. Whitman says that out of 5401 cases of tuberculosis of the joints seven-eighths occurred in subjects under fourteen years of age. The joints most commonly affected are in the order of frequency — the spine, hip, knee, ankle, elbow, shoulder, and wrist. The disease is usually monarticular but may involve more than one joint. Pathology. — The pathology is that of tubercle formation primarily in the spongy bone of the epiphysis and spreading secondarily to the joint. Nichols, after a careful microscopic examination of the material from more than 120 tuberculous joints, failed to find a single instance in which there was reason to believe that the disease primarily occurred in the synovial membrane, while Clarke and others have demonstrated primary synovial tuberculosis in a few adult cases. The process begins by a deposit of tubercle bacilli in the end vessels of the subchondral bone. This produces a typical tubercle with caseous centre, giant cells and surrounding connective tissue. The process may be here arrested but in most cases the area of necrosis and cheesy degeneration gradually extends peripherally, and finally ruptures into the joint, often by a minute opening through the articular cartilage. As soon as the tuberculous material gains access to the synovial membrane there occurs an acute miliary tuberculosis of that tissue, with congestion, exudation, necrosis and formation of granula- tion tissue involving the synovia, cartilages and bones which have a com- mon synovial sac. As the process advances the cartilages disappear, the bones become exposed and eroded, the extra-articular fibrous tissues become edematous and softened, the ligaments relaxed, and spon- taneous dislocation may occur. The resulting lesion as in non-tuber- culous inflammations, is first a synovial type with a great increase of synovial fluid, secondly the "pulpy" type, with fungating masses of granulation tuberculous tissue, and thirdly — the dry type, a sclerotic process leading to fairly stiff fibrous or bony ankylosis. If the joint capsule ruptures, the tuberculous material finds its way into the soft tissues, where it slowly extends in the direction of least resistance along the fascial plane, until it may finally rupture on the surface. This lesion of the soft tissues is spoken of as " cold abscess," and is unaccompanied by pain, tenderness, redness of the skin, or other evidences of inflammation. The fluid contents of a cold abscess consist of necrosed and softened particles of bone and cartilage, frag- ments of degenerated soft tissues, caseous material, polymorphonuclear leukocytes, a high proportion of lymphocytes, tubercle bacilli in small numbers, an occasional rice body and serum. It is called tuberculous pus. These cold abscesses may reach a large size and rupture at a considerable distance from the original bone focus, which may be comparatively small in extent. When they rupture there forms a sinus lined by granulation tissue leading down to the bony focus. Without secondary infection these heal as does any tuberculous TUBERCULOSIS OF JOINTS 785 process, but when so infected the healing is greatly prolonged and leads to long continued pus formation, and secondary waxy degeneration in the liver and kidneys. The termination of the tuberculous process, of whatever type, may be by death, or healing with absorption of the inflammatory product, death of the tubercle bacilli, cicatrization of the destroyed areas with possible calcification, and where the surface of the joint has been eroded, fibrous ankylosis, or if deeper, bony ankylosis. Carti- laginous ankylosis is a pathological curiosity. If the joint so heals the synovial membrane may be partly preserved. When one-quarter to one- half remains, mobility of the joint may be expected. Otherwise there will be stiffness, atrophy of the muscles about the joint and in the bones entering into its structure, of the same type as that found in other chronic joint inflammations, but of much greater degree. Symptoms. — The onset is nearly always gradual with the rare but conspicuous exception of the acute type already mentioned. Symp- toms of the onset are pain and disturbance of function causing protect- ing movements and attitudes in the use of the joints. Rarely, swelling may be the first symptom, especially in adults and in spinal tuberculosis of the lower lumbar region. The symptoms become fully manifest after a very variable period from weeks to many months. Chief of these is pain, referred to the diseased joint, or by irritation of nerve trunks to the areas supplied by them, the character is dull, continuous with sharp exacerbations. It is worse at night causing night cries and increased by any jarring or movements, it is relieved only by fixation and relief of pressure from the joint surfaces. Function of the joint is completely or partially lost because of the limitation of motion by mechanical deformities inside the joint, and secondly because of the marked muscular spasm holding the joint in the most comfortable position, which makes it almost impossible to estimate the range of motion without an anes- thetic. The appearance of the joint is altered, both by the occurrence of a fusiform swelling due to effusion or the presence of granulation tissue, and to an abnormal pallor of the skin (tumor albus). The deformity of the extremity is caused by the joint being held in the position allowing the greatest distension of the capsule, usually in mid-flexion, by subluxation of the joint and by marked atrophy of the muscle concerned, which is out of proportion to the atrophy of disuse. The general symptoms are those of any toxemia but perhaps less marked than with similar lesions caused by other agencies. The physical examination shows a wasted extremity, limited in active and passive motion, with a whitish swollen joint whose bony outlines are obliterated or obscured, giving the signs of fluid or a boggy sen- sation to the examining hand. Tenderness is general over the joint and more marked over the bone which is most involved. It is obtained by both direct and indirect pressure through the shaft of 50 780 INJURIES AND DISEASES OF JOINTS the bone. Muscle spasm is detected by comparing the range of motion before and during an anesthetic. Clinical course without treatment is progressively downward with the formation of cold abscesses, sinuses, waxy degeneration, and death. Under ideal treatment the general and local conditions improve in nearly all cases, so that it may be said that the prognosis depends in great measure on the financial ability to secure transportation to proper environment and to obtain the proper amount of local treat- Fig. 358. — Acute tuberculous arthritis of the knee. (Whitman.) ment. Under older conditions the mortality was 36 per cent, in the first decade of life, 40 per cent, in the second and in the third 72 per cent. Treatment. — General Treatment. — This should consist in measures to raise the general resistance of the patient, to combat the spread of infection, and to overcome the effects of toxemia. The regular diet should be of high caloric value. To this should be added extra diet rich in fat, as cream, cod-liver oil, or an excess of butter. Sleeping out of doors, the constant exposure of the body to fresh air and sun- shine, moderate exercise when possible, and other hygienic measures TUBERCULOSIS OF JOINTS 787 are indicated. Tuberculin treatment has been advised, but its effect is doubtful. Local Treatment — The removal of a small localized tuberculous bone focus, before rupture into the joint, is an ideal procedure, but the opportunity for this is rare. Where the joint is already involved, the treatment should be by fixation and traction. The former to over- come untoward effects of functional use, and the latter to remove pressure from the inflamed joint surfaces. The local resistance of the joint may sometimes be increased by active or passive hyperemia. The former may be brought about by heat, massage, counter-irritation, and the high frequency currents. The latter by constriction, or Bier's method of passive hyperemia. Heliotherapy as practiced by Rolier in the Swiss Alps has proved of the greatest value in a number of apparently hopeless cases. Whether the result is due to the bacteri- cidal action of the direct rays of the sun, or to the raising of the gen- eral resistance of the patient by the active out-door life, is impossible to determine. Probably both of these factors play a part in the pro- cess. It has been suggested that the joint resistance may be further raised, and possibly bacteria destroyed, by the injection of iodoform and glycerine, dilute solutions of formalin, or other slightly irritating antiseptic agents. Operative Treatment. — In general it may be stated that operative treatment is indicated in all cases where the primary bone focus can be removed before the joint has been invaded. In general, operative treatment is earlier indicated in adults, and in lesions of the lower extremities; conservative treatment being indicated in children, and in the joints of the upper extremities, where recovery with motion may be expected. It is a general principle in tuberculous joint disease, that if firm ankylosis can be established, the disease will become quiescent or disappear. For this reason, operation upon the spine and joints of the lower extremity with a view to bringing about ankylosis are to be advised in cases which have resisted conservative measures. In chil- dren arthrotomy with removal of the diseased cartilage, followed by fixation, is to be advised, for the reason that the more formal excisions are apt to interfere with the growth of the bone from injury to the epiphysis. In adults formal excisions are indicated. The details of these operative procedures will be mentioned under treatment of the various joints. Amputation is indicated to preserve life and where as in many cases of carpal infection erasion or excision promises an unsatisfac- tory, or extremely prolonged convalescence with an uncertain result. Operations devised to splint the infected joint, as in the spine, will be mentioned under that heading. The treatment of cold abscesses is conservative until rupture is imminent, or until pressure causes symptoms. They are opened under absolute aseptic precautions by means of a large trocar and canula with aspirating apparatus, or through small incisions which are 788 INJURIES AND DISEASES OF JOINTS immediately closed without drainage. The former is preferable where practicable, but with large cheesy masses in the cavity the second may be indicated. Secondary infection of a cold abscess converts a self healing process into an almost interminable draining wound. In the treatment of sinuses, drainage should be avoided as far as possible and the sinus sterilized with cautious application of pure phenol on a probe or injected through a small catheter by a finely graduated syringe. Emil Beck observed that sinuses filled with bismuth subnitrate mixture for radio- graphic purposes healed spontaneously, and working upon this basis he has pre- pared a mixture consisting of vaseline, bismuth subnitrate, white wax, and soft paraffin. This is fluidefied by heat and injected into the sinus up to the point of discomfort. The opening is next closed until the mixture has hardened and then covered by sterile dressing. After several hours or clays small bits of the mixture may be discharged, but occasionally the whole mass remains. The results are in the main good. TUBERCULOUS DISEASE OF SPECIAL JOINTS. Pott's Disease. — Pott's disease, or tuberculous spondylitis, is a tuberculous disease of the vertebral bodies. It is most common before the twentieth year, GO per cent, of the cases occurring in the first decade of life. The lower dorsal region is most frequently affected, al- though it may occur in any region. The disease usually begins in the body of one vertebral segment while the spinous processes are preserved. The bacilli lodge in the areas occupied by the terminal vessels, either (1) in the centre of the body, (2) near the epiphysis going on to the adjoining vertebra, or (3) superficially in the area supplied by the inter- costal arteries. It generally ruptures anteriorly, and may extend upward or downward beneath the prevertebral ligament and involve secondarily the bodies of other vertebra?. The intervertebral cartilage may become diseased in the later stages of the process. As a result of a caving in of the vertebral bodies which support the weight of the trunk, an angular curvature of the spine occurs, with Fig. 359. — Psoas abscess. TUBERCULOUS DISEASE OF SPECIAL JOINTS 789 the formation of a projecting knuckle of bone behind (Fig. 360). Under favorable conditions bony ankylosis and recovery may take place. In other cases a cold abscess forms, which, if the disease is located in the cervical region, may point in the pharynx, retropharyn- geal abscess, or at the side of the neck; if lower down, in the intercostal spaces near the spine, in the lumbar region, lumbar abscess, or, by entering the sheath of the psoas muscle, in the groin or thigh, psoas abscess (Fig. 359) . The abscess rarely ruptures into the pleural cavity, lung, or one of the abdominal organs. In many cases the abscess is not recognized during life. Pressure on the spinal cord, causing more Fig. 360. — Pott's disease. Spinal column divided longitudinally. or less complete paraplegia, may be due to bony deformity, but is com- monly the result of a tuberculous spinal pachymeningitis, or edema of the meninges and cord. Symptoms. — The prodromal symptoms are those of general toxemia persisting for a few weeks or several months without any focal symp- toms. The first symptom noticed may be the external appearance of a cold abscess. The onset, however, is usually of gradual pain, spinal rigidity, kyphosis, symptoms of first irritation and then paralysis of the spinal nerves, abscess formation and rupture, together with signs of a general toxemia. The pain is located at the site of disease or is referred by irritation of emerging spinal nerves to the corresponding 790 INJURIES AND DISEASES OF JOINTS skin area, usually the abdomen. The character is dull, continuous with sharp exacerbations, especially at night, causing night cries. It is made worse by any mechanical irritation, such as pressure during examination, or sudden movement or jars. Later in the disease there appear paralytic disturbances, paresthesia and anesthesia, together with motor paralysis because of nerve destruction by the lesion. Spinal rigidity is shown by the peculiar cautious gait and by the protective posture assumed in attempting to pick up objects from the floor or otherwise use the trunk (Fig. 361). On examination this is shown by palpating the firm contracted erector spina 1 , and by noting the lack of anteroposterior and lateral mobility Fig. 361. — Lumbar disease. The manner of picking up an object. (Whitman.) I^ig. 362. — Plaster jacket. of the spine by placing child on the abdomen, and with the lower extremities as levers swinging the hips upward, downward and laterally. Deformity is the result of the backward bowing of the spinous processes as the bodies of the vertebra? fall together anteriorly. These are usually single but may be multiple and occur as pointed knuckles or more rounded eminences with the spines of several vertebrae very prominent. Lateral deformity is not common and occurs in the early advancing cases because of the asymmetric destruction of the bodies. Compensatory lordosis occurs above and below the lesion together with deformity of the pelvis. Abscesses and fistula? depend on the line of least resistance along the spinal muscles as mentioned under pathology. TUBERCULOUS DISEASE OF SPECIAL JOINTS 791 Treatment. — General treatment is carried out as in tuberculosis in any form preferably in an institution. Local treatment aims to remove the pressure of the superimposed weight from the diseased vertebra, to prevent motion of the spine in any direction and to prevent or correct deformity. All three of these objects are attained in varying degree by each of the methods of mechanical treatment. The relief from the superimposed weight is best accomplished by the recumbent position which should be assumed in all very early .or advanced cases, during abscess formation, when apparatus becomes intolerable and when there is evidence of great softening of the vertebral body as indicated by the yielding of the spinal deformity when pressure is made over it. Pressure is further relieved by continued traction on the spinal column while recumbent, or by so constructing braces and plaster casts that they hold firmly the pelvis at their base and lift the upper trunk under the arms, and in lesions above the eighth dorsal vertebra by a jury mast supporting the head. Fig. 363. — The Bradford frame bent to assure overextension of the spine. (Whitman.) Fixation of the trunk is attained by a snugly fitting plaster cast (Fig. 362), by strapping securely on a Bradford frame (Fig. 363), and by the use of a system of rigid braces. The Taylor brace directly combats the tendency to kyphosis by pressure over the knuckle and counter pressure against the pelvis and shoulder girdle (Fig. 364). The prevention and correction of deformities is daily assuming greater importance. Because of the danger of rupturing tissues loaded with tuberculous material, and injury to the vessels and nervous tissues, the method of Calot of forcibly reducing the deformity under an anes- thetic has given way to slower but none the less complete methods. The mechanics of all the methods are the same; pressure of as high degree possible on the apex of the deformity with more or less counter pressure on the shoulders and pelvis, together with more or less trac- tion from above and below to elongate the spine. Goldthwaite accomplishes this with a special apparatus for pressing forward on either side of the gibbus by heavily padded and shaped parallel wires, accompanied by traction on the head and lower limbs. Extension of the spine is accomplished by the weight of the supine unsupported upper and lower portions of the body. Whitman bends a Bradford 792 INJURIES AND DISEASES OF JOINTS frame to the proper angle using the canvas sheet to give the pressure on the gibbus. Tubby uses a curved split pillow with room for the most prominent skin surface to escape pressure. Bradford follows the same principle by a pillow in his frame and pressing on the gibbus. Tunstall Taylor uses a device called a Kyphotone to forcibly extend the spine while pressure is being exerted on the gibbus, and when the deformity is sufficiently corrected to apply a plaster cast to preserve the new shape. In a still more gradual way the plaster cast and espe- Fig. 3G4. — The Taylor brace and head support applied for disease of the upper dorsa region. (Whitman.) cially the Taylor brace accomplish the same result in ambulatory patients. The operative methods for accomplishing the above principles aim at developing a bony splint to support the spine at the diseased area. Albee accomplishes this by splitting sagitally the spines of the diseased vertebra? together with the two or three above and below, and in this cleft inserting and fastening a splint about three millimeters thick and two centimeters wide shaved from the tibia. This graft grows and forms a solid bony column for the support of the body weight. TUBERCULOUS DISEASE OF SPECIAL JOIXTS 793 Done in cases not far advanced it shortens the treatment greatly and thus far has given permanent results (Fig. 365). Another and equally successful method of accomplishing this result is the procedure of Hibbs. He removes the periosteum from several spinous processes and the corresponding laminae, partly divides the processes, and by fracturing them near their bases and forcing them Fig. 365. — X-ray photograph of transplanted bone splint in the spines of the vertebra. G-G', bone graft; T, focus of disease in vertebra. downward in contact with the denuded lamina?, brings about a bony anchylosis of the diseased area. Cold abscesses and sinuses have been considered above. Paralysis is best avoided by the recumbent position with the first symptom. Forcible reduction is occasionally followed by a slight increase of paralysis but is generally later followed by rapid improvement. 794 INJURIES AND DISEASES OF JOINTS The operative removal of tuberculous vertebral sequestra is seldom undertaken because of the good results to be expected of conservative treatment and the uncertain results of operation. Tuberculosis of the Hip. — Hip disease, morbus coxae, or tuberculous arthritis of the hip-joint, is essentially a disease of childhood and youth. 206 out of 241 cases reported in Alfer's table occurred before the twentieth year. The disease may begin in the spongy tissue of the head of the bone near the upper epiphyseal line, less often in the acetab- ulum. In either event the synovial membrane is quickly involved, and there is extensive destruction of the articular cartilages and the bone, with osteophytic growths, masses of granulation tissue, relax- ation of the ligaments and sponta- neous dislocation. Symptoms. — A slight limp is gene- rally the first symptom, with some pain and stiffness of the joint after an unusual amount of walking. The pain is often insignificant and may be referred to the region of the knee. Sudden paroxymals pains and " night cries" are frequent as the disease advances. When an effusion occurs in the joint the limb is slightly flexed, abducted, and rota- ted outward. There is slight fulness in the upper part of Scarpa's trian- gle, and a partial obliteration of the gluteal fold. Tenderness exists about the hip, and forcing the head of the bone against the acetabulum by striking the trochanter or knee is painful. There is noticeable limi- tation of motion with well-marked muscular rigidity. This is occa- sionally spoken of as the stage of apparent lengthening. As the disease progresses there is considerable deformity, due to flexion of the limb and tilting of the pelvis. Walking becomes more and more painful and the patient finally becomes bed- ridden. Atrophy of the muscles of the thigh and leg is always present at this stage of the disease, and abscesses may appear. Together with these local symptoms there are afternoon fever, loss of flesh and strength, and general bodily weakness. When the head of the bone is destroyed or the rim of the acetabulum has broken down, upward traction by the muscles results in luxation of the head or neck of the bone, and the formation of an abscess in the soft tissues. The position Fig. 366. — Thomas splint applied with patten and crutches. TUBERCULOUS DISEASE OF SPECIAL JOINTS 795 of the limb is then changed to one of flexion, adduction, and internal rotation. Bony ankylosis and recovery may take place at any period of the disease, but extension of the disease to other organs, and general ill health from prolonged suppuration and suffering, are apt to bring about a fatal termination. Treatment. — General treatment has already been considered. Local Treatment. — In the early stages with the patient recumbent the joint surfaces are separated by traction of the thigh in moderate abduction and flexion (Fig. 366) which gives better results than simple fixation. With the subsidence of acute symptoms, fixation in this position is accomplished by plaster spica or Thomas splint (Fig. 366) with a high-soled shoe on the sound foot. The favorable effect of traction by the Taylor or Sayre traction splint, which allows walking without crutches, is recognized by most surgeons. Whitman has devised a splint which insures both fixation and traction (Fig. 368). Fig. 367. — A method of reducing flexion in hip disease. The brace is adjusted to the angle of deformity, and in addition to the direct traction of the apparatus weights are attached to the brace itself. In the illustration counter-traction, by means of perineal bands attached to the head of the bed, is shown. (Whitman.) For a description of these splints and the method of their application, the reader is referred to standard works on orthopedic surgery. If conservative treatment fails to arrest the disease, or if life is threatened by persistent suppuration, excision or amputation is as a last resort to be recommended. Excision of the Hip. — The patient is anesthetized and placed on the sound side. An incision is made from a point two inches above the tip of the great trochanter to two or three inches below, parallel with the shaft. The tissues are divided down to the periosteum, the muscular attachments to the tuberosity are separated with a thin layer of cartilage or bone and well retracted, the joint capsule opened, and the head of the bone dislocated. The diseased portion is then removed with the saw or bone-forceps, the acetabular disease removed with a Volkmann spoon, the joint cavity thoroughly swabbed with pure carbolic acid or a solution of formalin, and the wound closed tight unless there is secondary infection. Extra capsular resection (Barden- 79C> INJURIES AND DISEASES OF JOINTS heuer) in which there is removal of acetabulum aud upper femur en masse, has been used for extensive disease of the acetabulum. Amputation at the hip-joint is indicated in hopelessly diseased limbs. The final results of hip disease vary greatly, depending upon the opportunities for early efficient treatment. The death rate reported by Sayre in 212 private cases was only a little over 2 per cent. The hospital death rate is from 12 to 30 per cent. The functional result of the cured cases treated conservatively depends largely upon the amount of care which is exer- cised in the treatment. Tuberculous Arthritis of the Knee.— Although knee-joint tuberculosis is more common in childhood, yet a fair propor- tion of the cases (more than one-third) develop in individuals over twenty years of age. The disease may begin in any of the bones which enter into the formation of the joint, or possibly in the synovial membrane. Epiphysitis of the tibia is, however, the most frequent primary focus, and disease of the femur next. Symptoms. — In this, as in hip disease, early lameness, stiffness, and pain in the joint constitutes the first symptoms. Night cries are less frequent, but tender- ness is more marked. There are usually early tenderness and thickening of the articular extremity of the tibia or femur. An early synovial effusion may be the first symptom, but this does not neces- sarily argue in favor of a primary syno- vial focus, for it occurs in painless epi- physeal foci of disease, before the joint is infected. When the joint is finally invaded, there is the gradual develop- ment of a boggy fusiform swelling, with muscular rigidity, fixation of the limb in a partly flexed position, and atrophy of the muscles of the thigh and leg (Fig. 369). The lameness becomes more marked, flexion increases, and general deterioration of the health ensues. As the disease ad- vances, the ligaments become softened and relaxed, and a sponta- neous backward subluxation with rotation occurs, which, with the oval fusiform swelling, gives to the leg a characteristic appearance. Abscess formation is less frequent than in hip disease. Fig. 368.— Whitman's splint. TUBERCULOUS DISEASE OF SPECIAL JOINTS -'.»; Treatment. — In the early stages of the disease it may he possible to locate and remove the bone focus before it has broken through the cartilage and infected the joint. Where the joint is involved the treat- ment should be conservative. Rest in bed with traction by means of a weight and pulley will relieve pain, correct deformity, and overcome muscular spasm. The direction of the traction is in the direction of the leg as held in it- deformed position and not in the direction of the thigh. When this is accomplished the joint should be fixed with a plaster-of-Paris cast extending from the groin to the ankle, or by a Thomas knee-splint (Fig. .'!7n . A high-soled shoe should be pro- ^q: Fig. 369. — Synovial tu the knee. Fig. 370.— The Thomas knee- splint. vided for the sound foot and the diseased knee protected by the use of crutches; or if the upright bars of the Thomas splint extend below the foot and are joined by a metal plate, the patient may discard the crutches and walk upon the splint. Operative treatment is indicated if the disease advances or if abscesses form and rupture, erasion in children, excision in adults. Erosion. — A downward curved incision should be made across from one condyle to the other in front of the joint below the patella. The joint should be freely opened and flexed, the diseased synovial membrane curetted, any diseased areas in the cartilages and bone 798 INJURIES AND DISEASES OF JOINTS thoroughly scraped out by the sharp spoon, and the entire interior of the joint disinfected with pure carbolic acid or a solution of formalin. If there is a mixed infection with marked sepsis, the cavity should be packed and the leg held in a flexed position (Mayo) ; in other cases the limb should be straightened, the wound united without drainage, and the leg placed on a posterior splint. Recovery with bony ankylosis is the best result to be expected. Excision of the Knee. — The joint is exposed in the manner just described, the leg acutely flexed on the thigh, and the patella and all exposed portions of the diseased synovial membrane removed. The crucial ligaments are next divided, and the articular ends of the femur and tibia sawn off at such an angle as to insure three or four degrees of flexion when the leg is straightened and the cut surfaces of the bone brought snugly together. The bones are held in place by two heavy catgut sutures passed through holes made with a drill. The soft parts are united and the leg dressed and held in position by a posterior splint or plaster cast. As in other cases of progressive tuberculous joint disease, amputation may be necessary as a life-saving measure. The prognosis in tumor albus of the knee is less serious than in tuberculous disease of the spine or hip. Excellent functional results are often obtained by early painstaking conservative treatment. The result of excision in adult cases' is generally satisfactory. The death rate is low. Tuberculous Arthritis of the Ankle. — Tuberculous arthritis of the ankle is a comparatively rare affection. Two-thirds of the cases occur in individuals under twenty years of age. The disease attacks the astragalus primarily in the majority of instances, but it may occur in either malleolus. Symptoms. — The disease not infrequently follows a sprain, which injur}' may act as an exciting cause, either by lowering the resistance of the joint tissues, or by awakening a latent bone focus. There are stiffness and pain about the joint, with limitation of motion and the formation of boggy swellings in front of and behind the malleoli. The patient limps, and in walking the foot may be rotated outward. There are well-marked muscular rigidity and some atrophy of the muscles of the calf. If the disease is limited to the subastragaloid joint, there is pain on lateral movement of the os calcis; plantar and dorsal flexion may be perfect (Whitman). Treatment. — The foot should be encased in a plaster cast, which prevents all motion in the joint and keeps it at a right angle with the axis of the leg, and protected from all use by crutches. Operative treatment should be delayed as long as there is any hope of recovery by conservative measures, as the results of excision or arthrectomy are, as a rule, unsatisfactory. Whitman strongly advises removal of the astragalus when this is found to be the seat of the primary focus. To accomplish this, the joint should be freely opened TUBERCULOUS DISEASE OF SPECIAL JOINTS 799 from the outside by a curved incision beneath the external malleolus, and extending well forward over the joint. The peronei tendons are divided, the external lateral, and if necessary part of the anterior and posterior ligaments are incised, the foot sharply inverted until the sole is directed upward, sacrificing the internal malleolus if neces- sary. The astragalus is separated from its connections with the other bones of the tarsus; the os calcis is shaped to fit the tibiofibular mortice, the foot replaced, the ligaments and tendons united and the cutaneous wound sutured with superficial drainage. Tuberculous Disease of the Other Tarsal Bones. — Tuberculous disease of the other tarsal bones is occasionally encountered. Of these, the calcaneum and cuboid are the ones most frequently affected. The treatment differs in no respect from thatof other tuberculous joints. Tuberculous Arthritis of the Shoulder. — Tuberculous arthritis of the shoulder is a rare affection. The disease may begin in the head of the humerus or in the glenoid cavity. Symptoms. — The earliest symptoms are pain, stiffness, muscular spasm, and swelling. The pain may be referred to a point near the insertion of the deltoid muscle. A tender point is generally found just below the tip of the acromion. Fever and general failure of health occur late. Muscular atrophy may be well marked, especially of the deltoid. The bone is generally enlarged, and the entire region of the joint appears broadened. Abscesses may occur and point near the anterior or posterior border of the deltoid muscle. Treatment. — The treatment should be the same as in other tubercu- lous joint affections: rest, fixation, and the avoidance of jars and other traumata. The use of the sling and chest-binder will often give relief, or the plaster spica of the shoulder and arm may be employed. Excision of the shoulder may be required if the disease is progressive. The Anterior Method. — A longitudinal anterior incision should be made either through the deltoid muscle or between it and the pectoralis major. The joint should be opened and the head of the bone resected by the subperiosteal method, if that is possible. This saves the attachment of the muscles and renders more probable future use of the arm. After the diseased tissues are thoroughly removed the wound should be closed without drainage. Kocher's Posterior Method. — The incision runs from the tip of the acromion backward along the posterior border to the spine of the scapula, turns sharply downward to the posterior fold of the axilla. The supraspinatus and infraspinatus attachments are cut. The posterior margin of deltoid is cut and with a chisel the root of the acromion is severed. This with the deltoid is carried outward, the fibres of the external rotators are cut exposing the capsule which is opened, and the diseased matter removed. This completed, the acromion is sutured in place and muscles and skin resutured. In the majority of instances in which recovery follows, a fairly useful limb results. 800 INJURIES AND DISEASES OF JOINTS Tuberculous Arthritis of the Elbow. — -Tuberculous arthritis of the elbow is more frequent than disease of the shoulder or wrist. It is common in early adult life. The primary infection may be in the olecranon or the external condyle of the humerus. Symptoms. — The symptoms are pain, stiffness, and limitation of motion in the joint. Inability to extend the forearm completely is often the earliest sign of the disease. The joint later becomes enlarged, the swelling at first appearing on either side of the olecranon and tendon of the triceps and obliterating the normal depressions in these localities. As the disease advances the joint becomes fixed, usually in a position midway between flexion at a right angle and full extension. The swelling increases and produces a fusiform boggy tumor. Suppuration may occur, sinuses form, and the entire articulation becomes a pulpy granulating mass. Treatment. — The conservative treatment of this joint should not be too long attempted, as the results are not satisfactory. If fixation and general hygienic measures do not promptly arrest the progress of the disease, excision is indicated. Excision of the elbow may be accomplished in the following manner: Under general anesthesia a longitudinal incision is made over the back of the joint, the centre of which will lie over the olecranon. When all the tissues are divided down to the bone and well retracted, the perios- teum of the olecranon and upper part of the ulna should be incised together with those of the humerus, and the soft parts separated from the bones on either side until the condyles are freely exposed, care being taken to avoid injury to the ulnar nerve. The arm is then acutely flexed and the articular surfaces of both bones made to protrude from the wound. In erasion of the joint only the diseased portion is curetted away while in excision the ends are totally removed. Care is taken in exposing the joint to preserve the anconeus fascial expan- sion of the triceps so that subsequent motion may be secured. If primary union occurs an attempt may be made, two or three weeks after operation, to change the position of the arm — increasing or diminishing the degree of flexion every forty-eight hours. In this way anchylosis occasionally may be avoided. Tuberculous Arthritis of the Wrist. — Tuberculous arthritis of the wrist is rare in childhood, and comparatively infrequent at any age. Any one or all of the joints may be affected. Symptoms. — The symptoms are pain, stiffness, swelling and limita- tion of motion, with muscular atrophy and general ill-health. The swelling is more marked on the dorsal aspect of the wrist, and may be fusiform in shape. Fluctuation may be detected at any early period, but is soon replaced by a boggy induration. Treatment. — The treatment should consist in rest on a splint and compression, as pressure here seems to give a large measure of relief (Bradford and Lovett). Excision of one or more of the bones of the wrist is indicated in advanced disease but gives only a fair prognosis. The best incision to expose the lesion is a longitudinal one over the TUBERCULOUS DISEASE OF SPECIAL JOISTS 801 back of the wrist, between the extensor tendons of the thumb and those of the index finger. These tendons are separated with retractors, and the long and short extensors of the wrist brought into view and retracted. The attachment of the short extensor to the third meta- carpal bone is next divided, and the carpal bones well exposed by wide retraction of the tissues. Only the bones that are diseased should be removed. The use of the glutol or formalin gelatin powder here and in other tuberculous cavities has been found by the author to bring about healthy granulation and often complete healing in what seemed to be hopeless cases. After closure of the wound with drainage, the arm should be placed on a palmar splint and kept at rest until evidence of tuberculosis hasdisappeared. Amputation is often made necessary because of the un- satisfactory result from wrist resection and from progression of the disease. Sacro-iliac Disease. — Tuber- culosis of the sacro-iliac joint is a rare affection. It occurs chiefly in young adults. Symptoms. — The symptoms in the beginning are obscure, and often resemble those of lumbar Pott's disease. There is pain on standing or walking, and on pressing the iliac crests together; the patient limps, and instinctively rests his weight upon the healthy leg. On walking the spine has a lateral deviation, and the motion of the legs is chiefly below the knees. This gives a shuffling characteristic gait. A cold abscess may form and point in the gluteal region or burrow deep in the pelvis. Treatment. — Rest in bed, with extension during the acute stage. Later, a pelvic binder and crutches. Abscess in the pelvis may be reached by a posterior incision with resection of a portion of the ileum (Van Hook). Neuropathic Arthropathy. — Neuropathic arthropathy (Charcot's Joint) (Fig. 371 j is an example of the reaction against normal irritation 51 Fig. 371. — Tabetic arthropathy (Charcot's disease) of the knee-joint. Insane patient with locomotor ataxia. Relaxation of liga- ments. Effusion and numerous loose bodies in joint. Absorption of articular surfaces. Functionally useless, painless joint. (Carnett). 802 IX JURIES AND DISEASES OF JOINTS of the perverted adaptive power of a joint due to disturbance of nerve supply. From pathological study it has been inferred that the process is the direct result of the Spirocheta pallida, but this is yet to be established. It most frequently follows tabes; more rarely syringo- myelia and anterior poliomyelitis. The pathology is the same as the fungous type of chronic arthritis with effusion, degenerative changes and bony outgrowths predominating. Symptoms. — The symptoms have an acute onset reaching a maximum in a few days and often going on to complete joint destruction in a few weeks. The joints involved correspond to the section of the cord affected, usually the knee, less often the shoulder, hip, and elbow. It is usually monarticular but may be bilateral. The joint is greatly distended. There is great abnormal mobility with subluxation. The skin is normal with dilated veins. There may be subcutaneous edema. Pain is absent and the x-rays present a picture of bony overgrowth and degeneration of the bone end with osteoporosis. Treatment. — Treatment is by mechanical support, rest, and meas- ures directed against the original infection. Pulmonary Osteoarthropathy. — Pulmonary osteoarthropathy is a condition occurring in chronic inflammation of the intrathoracic struc- tures and characterized by the thickening of periosteum of the long bones and chronic hyperplastic inflammatory processes in the joints similar to chronic progressive polyarthritis. Its exact nature is un- known but from the pathology and' clinical course it has been assumed to be infectious. Chronic Synovitis. — Chronic synovitis is the result of continued mechanical irritation by a foreign body, loose meniscus, thickened synovial fringe, badly approximated joint surfaces, as in static changes due to flat foot or knock-knee, and possibly by a bloody effusion into the joint. It is also caused by mild gout and by avirulent infection. Symptoms. — Symptoms are those of a distended joint with fluctua- tion, slight discomfort and limp. The course is chronic dependent on the cause. Treatment of chronic serous synovitis consists in rest, counter- irritation, massage, hydrotherapy, compression, and the use of hot- air baths. Counter-irritation is produced best by the application of the actual cautery, fly blisters, or painting with iodine; compression by the use of the rubber bandage or an elastic stocking or cap; the hot-air bath requires a special apparatus, which is pictured in Fig. 372 . If these means fail, the joint may be emptied by aseptic aspira- tion and immediate compression applied by a rubber bandage; or open arthrotomy may be performed for purposes of exploration. This treatment should be followed by a period of rest of from two to three weeks. A form of intermittent swelling of the joint ( Hydrops artiddorum intermittens) occurs with marked regularity, is bilateral, of sudden NEW GROWTHS OF JOINTS so:; onset and subsidence, but chronic course and has been thought to belong to the same class as angeioneurotic edema. Hemarthrosis. — Hemarthrosis is a rare condition occurring in bleeders usually in the young. It occurs spontaneously or after insignificant trauma. There are in the early attacks signs of clotted blood in the joint with effusion which may subside with no sequela 3 . With more frequent attacks there are irritation and the production of a pathological and clinical picture diagnosed with difficulty from tuberculosis and chronic progressive arthritis, with fungous and bony growth and erosion of the cartilages, producing joint deformity and contractures. Treatment. — The treatment is by absolute rest and mild pressure, together with the treatment of the hemophilia. Fig. 372. — The Frazier-Lentz hot-air apparatus. NEW GROWTHS OF JOINTS. New growths of the joints may be osteoma, chondroma, and lipoma. Whether these are inflammatory products or true neoplasms is difficult to decide. Osteoma, composed of cancellous bone, occurs at the bone end, grows at the edge of the cartilage, often becomes pedunculated or broken off from the bone, when it acts as a foreign body. Chondroma of the articular cartilage is rare. In hypertrophied joint fringes especially in villous arthritis there may be the forma- 804 INJURIES AND DISEASES OF JOINTS tion of cartilaginous centres through metaplasia. In structure they do not differ from chondromata. They are the most frequent source of joint mice. Lipoma of the joint occurs as a shaggy growth of the synovial membrane (lipoma arborescens) in gross appearance like villous ar- thritis but on microscopical section showing adult and embryonal fat cells. Malignant tumors are extremely rare. The treatment of all new growths is excision. ANKYLOSIS. The loss of motion in a joint is spoken of as ankylosis. This may be due to trauma resulting in fracture and bony deformity; to inflam- mation, giving rise to fibrous adhesions, loss of cartilage, and bony union of the joint surfaces (synostosis); to exostoses; to muscular contractures; or to the formation of periarticular adhesion or cica- trices. Treatment. — The prophylactic treatment by massage, passive motion, hydrotherapy, electricity, etc., has already been mentioned in the sections devoted to the various injuries and joint lesions giving rise to ankylosis. After ankylosis has once occurred, however, the problem is a far more difficult one. When the ankylosis is due to muscular contractures or scar tissue, much can be accomplished by tenotomy and plastic operations; when due to vicious union of fractures involving the joint surfaces, open operation and readjustment of the fragments will sometimes bring about a restoration of function. In the early stage of fibrous ankylosis, forcible rupture of the adhesions under general anesthesia, followed by persistent passive motion will occasionally be successful, but the pain is often severe, and a gradual return to the former condition almost inevitable. In chronic non-tuberculous arthritis where there is a marked tendency to bone formation, forced movements not infrecpiently accentuate the pathologic progress and do positive harm. A large number of experiments have been made with a view to restoring motion in these hopelessly ankylosed joints by means of open operation, separation of the joint surfaces, removal of the syno- vial membrane and implanting various substances, as ivory, celluloid or silver plates, rubber tissue, or animal membrane between the articulating bones. Some brilliant successes have been obtained by Murphy and others in the use of layers of aponeurosis, fatty tissue and muscle for transplantation, either attached by pedicles or freely transplanted from one part of the body to another. 1 Buchmann 2 has recently reported 2 cases where he successfully transplanted an un- 1 Jour, of Amer. Med. Assoc, May 20, 1905. 2 Zentralblatt fur Chirurgie, 1908, No. 19. ARTHRODESIS si >."> opened first metatarsophalangeal joint to the elbow region after excision of the ankylosed elbow-joint. In both instances the wounds healed and painless voluntary motion was obtained, in one ease through an arc of 30 and in the other through an arc of 70 degrees. Lexer 1 has successfully transplanted the articular surfaces of the knee-joint with crucial ligaments, from a freshly amputated extremity. Further experiments along these lines, it is hoped, will furnish data upon which to base final conclusions. ARTHRODESIS. In certain cases of paralysis, or in other instances where an exces- sive and uncontrolled mobility of a joint is present, the usefulness of the limb may be increased by obtaining firm bony ankylosis. To the procedure which produces such ankylosis, the term arthrodesis is applied. The method usually adopted is to expose the articular surfaces by a suitable incision, and then to remove by knife, curet, or saw the greater part of the articular cartilages after which the wound is closed and the limb retained in the most favorable position by a plaster cast. Where numerous small bones are to be fixed and where the complexity of the joint structure would make such a procedure tedious or danger- ous good results have been obtained by the use of metal spikes fasten- ing the bones together, or even the implantation of bony splints, by free transplantation, in such a way as to secure immobility of the joint. The operation is most frequently indicated in cases of infantile paralysis of the lower extremity, where nerve or tendon grafting is for any reason impracticable. The cut surfaces are held by phosphor-bronze wire, chromic catgut sutures, metal plates, or bony splints. 1 Arch. f. klin. Chir., vol. xc, No. 2. CHAPTER XXIX. FRACTURES. The term fracture, in its surgical sense, signifies a break or violent separation into two or more fragments of a bone or cartilage. A simple fracture is one which is covered by unbroken soft tissues. A compound fracture is one in which the bone lesion is exposed by a wound of the overlying parts. A comminuted fracture is one in which the bone or cartilage is broken into a number of small fragments. The terms transverse, oblique, longitudinal, spiral, T- or Y-shaped, are commonly used to indicate the general direction of the line or lines of separation. A fracture is said to be impacted, when one fragment is forcibly driven into another and remains more or less fixed in that position. The terms single, double, multiple, recent, old, united, and ununited, are frequently used in describing fractures, the significance of which will be readily understood. Injuries of bene or cartilage which do not result in complete separa- tion are sometimes spoken of as incomplete fractures. These are sub- divided into fissures or cracks without displacement of fragments; green-stick fractures, where a portion of the shaft of a long bone is fissured, the remaining portion bent — these conditions are not infre- quently encountered in children, and are often difficult of recognition; depressions, where a portion of a flat bone is driven inward; and separations at the epiphyseal line before complete union has been effected, occurring therefore in early life. Etiology. — The predisposing causes of fracture are, in general, conditions which render the bones more friable, such as the physio- logic atrophy of old age, malnutrition from any of the wasting diseases, new growths, osteomyelitis, or the lesions of syphilis or tuberculosis. The exciting causes of fracture are either external violence, muscular action, or a combination of both of these agencies. External violence may be direct, where the break occurs at the point of injury; or indirect, where it occurs at a distance from the point of application of the injuring force. A depressed fracture of the skull from the blow of a hammer would be an example of a fracture by direct violence; a fracture of the clavicle from a fall on the hand would be an example of one by indirect violence; a fracture of the patella occurring during an attempt to jump would be an example of one by muscular action; a blow on the point of a rigidly flexed elbow, fractur- ing the olecranon, would furnish an example of a fracture by both direct violence and muscular action. PLATE XXIII After /4i"ear Time of Bony Union of the Various Epiphyseal Junctions. 1! UP AIR OF FRACTURES 807 Repair of Fractures. — The processes of repair in fractured bones arc practically the same as in wounds of the soft parts. As the bone breaks there is a considerable laceration of the surrounding muscles and fasciae, blood is effused, and the periosteum may be stripped from the ends of the bone. If the fracture is quickly reduced and the bony fragments are accurately replaced and securely held in their normal position, the process is very simple. There is, at first, a reactionary hyperemia followed by an exudation of lymph which solidifies around the broken fragments, and encloses the blood clot, torn muscle, fascia, and periosteum. This soon becomes vascularized, and is gradual Fig. 373. — Fracture three weeks old; perios- teal and medullary callus partly ossified, partly cartilaginous: P, periosteum; K, bone; M, med- ulla. (Tillmanns.) Fig. 374. — Fracture healed with deformity (callus luxur- ians). (Tillmanns.) converted into fibrous tissue: it constitutes the provisional callus, and is the hard fusiform mass felt around the broken fragments after the first week. At a later period this mass becomes calcified; the part between the broken fragments remains as the permanent callus; the external or ensheathing callus, as well as the internal, central or medullary callus, is gradually absorbed (Fig. 373). If the broken fragments are not accurately replaced, if there is overriding, or if there is constantly more or less motion between the fragments, the process is slower, the primary exudate greater, and more or less of the ensheathing callus may remain as a permanent bridge between the fragments (Fig. 374). 80S FRACTURES In compound fractures, if the wound can be thoroughly cleansed and united, primary union may take place and the process may be the same as in a simple fracture. If, however, the wound is infected or for any other reason cannot be closed, healing takes place by gran- ulation. Necrosis of the denuded ends of the bone is very likely to occur under these conditions, small fragments from time to time becoming detached and appearing among the granulations, indefinitely delaying permanent closure of the wound and repair of the fracture. If the soft parts heal rapidly, the necrosed fragments of bone may become surrounded by the ensheathing callus and absorbed, or later removed by operation. Diagnosis. — Distinction must be made between the symptoms of the fracture itself, those due to any displacement of fragments, and those due to associated lesions. The subjective symptoms of the frac- ture are pain and impairment of function. The objective symptoms are localized tenderness and abnormal mobility. Deformity and crepitus are associated with displacement of the fragments. The swelling, ecchymosis and abrasions of the outlying parts belong to the associated injuries. Deformity often may be appreciated by inspection alone, by palpation, or by comparative measurements. Not infrequently the deformity is produced only by manipulation. Abnormal mobility may be made evident by the muscular efforts of the patient or by the examination of the surgeon. Crepitus is the feeling imparted to the hand of the examiner by the rubbing together of two or more fragments of bone; occasionally it is heard as well as felt. An attempt to elicit this sign, however, should rarely be made if it involves additional trauma. In the diagnosis of fractures it is important that a methodical examination be made in every suspected case, definitely establishing the presence or absence of as many of the above symptoms and signs as can be elicited without causing additional trauma. The surgeon should proceed in the following manner: First obtain from the patient or a witness an accurate account of the accident; then a statement of the immediately resulting impair- ment of function, as the ability to walk after the injury of a leg, use of the arm or hand after injury of that member; the mental condition after a head trauma; the presence or absence of cough or bloody expectoration after a crush of the chest; or the passage of blood from the rectum or bladder after injuries about the pelvis. The part should then be inspected after a careful removal of the clothing. If a wound of the soft parts be found, suggesting the pos- sibility of the fracture being compound, this at once should be swabbed with tincture of iodine and protected by a clean dressing to avoid further contamination during the subsequent examination. In injur- ies accompanied by marked and characteristic deformity it is often possible to arrive at a positive diagnosis of fracture at once by inspec- DIAGNOSIS K09 tion of the part, and in such case it is preferable not to proceed further with the examination until ready to reduce the fracture and apply the first dressing, as repeated moving and manipulation of fractured limbs, especially if accompanied by severe injury of the soft parts, is unneces- sary, extremely painful, and dangerous. If the diagnosis is not established by inspection, the limb should than be gently palpated and the area of greatest tenderness ascer- tained. The outline of each bone should next be felt from its upper to its lower extremity, and any deformity or point of special tender- ness noted. Abnormal mobility should be gently sought for and the exact point noted; crepitus if obtained is a very valuable symptom but search for it adds further unnecessary trauma. In fractures of the shaft of the femur, by simply placing a hand under the seat of injury and raising the limb-, angular deformity, mobility, and crepitus may often be demonstrated. In other instances, especially in fractures near the joints, gentle traction and rotation will often elicit these signs. In fractures of both bones of the leg .these signs are easily made evident by the gentlest manipulation. Fractures about the wrist, elbow, or shoulder are generally made out by their character- istic deformity or by careful palpation during flexion, extension, and rotation of the joint with traction on the limb. Deformity and abnor- mal mobility are generally absent in fractures of the ribs. Crepitus is obtained best by pressure over the ribs during deep inspiration and expiration. It often may be elicited by the use of the stethoscope placed over the point of greatest tenderness, the grating sound being heard during the movements of respiration. Mobility and crepitus in fractures of the pelvis are obtained best by pressing together the crests of the ilia or by direct palpation of the pubic arch, rami, or sacrum by rectal or vaginal examination. In fractures of the skull or spine the above-mentioned positive signs are often wanting; the diagnosis must be made by the z-rays, exploratory operation or the evidences of visceral injury. The use of the a-rays in the diagnosis of fractured bones has been found of the greatest service, and their employment should be a matter of routine wherever fractures are treated. While it may give an exag- gerated picture of deformity in comparatively unimportant variations from the normal, and its constant use may in a measure lead us to ignore and discard other methods, yet the fact must be admitted that by its employment a far more accurate idea of a given injury can be obtained than by any other method, and its use should be strongly recommended wherever it is possible. Plates should always be taken in two different planes: before reduction if possible, so that the at- tempt at reduction shall be as simple and purposeful as possible; and always after reduction to ensure the best possible adjustment. It is safer to again examine the fracture in this way at later intervals to be sure the reduction has been maintained. 810 FRACTURES Complications. — In nearly all fractures there is more or less bruising or injury of the soft parts, due to the trauma which produced the bone lesion. When this is not accompanied by extensive laceration of the skin or muscles, nor by injury to the nerve trunks or vessels, it is unimportant. Compound Fractures. — If a wound in the soft parts leads to the seat of fracture, constituting a compound fracture, the condition is serious, and should receive the most thorough and prompt attention, for infec- tion in a case of compound fracture gives rise frequently to the most virulent forms of septicemia. Previous to the introduction of the modern aseptic and antiseptic methods of wound treatment, in the great majority of instances compound fractures of the extremities were rapidly fatal or the patient recovered only after either amputa- tion or a prolonged osteomyelitis, and while the modern methods of dealing with such conditions have, to a great extent, removed these dangers, and by appropriate treatment the majority of such cases may be saved, it should not be forgotten that in compound fracture of any Fig. 375. — Volkmanu's contracture. of the larger bones we have a condition which may result fatally, and one in which this result can be avoided only by the most thorough antiseptic treatment. Ischemic Paralysis. — This rare but important complication of fracture is a pressure paralysis, caused by the temporary absence from the tissues of oxygenated blood, and often results in complete and permanent loss of function of an extremity. The lesion was first described by Volkmann in 1880. Since that time many cases have been reported in the literature. It is probable that the lesion is far more common than is generally supposed, but that it is not generally recognized, or the symptoms attributed to other causative factors. In the great majority of cases the lesion occurs in children and in the upper extremity (Fig. 375). Tight bandaging, the application of a plaster-of- Paris circular cast or of snugly applied wooden splints immediately after an injury may cause progressively increasing pressure on the soft tissues as the reac- tionary swelling occurs. This gives rise to an acute ischemia of the parts, which, if unrelieved for six or more hours, produces marked COMPLICATIONS 811 degenerative changes in the muscles and nerves, resulting in paralysis, contractures, sensory, and trophic disturbances. Other factors are sometimes present, as large hematomata, thrombosis of the vessels, and direct nerve injury, but the essential feature is an absence of blood supply to the muscles. The symptoms of this condition are pain, coldness, edema, and cyanosis of the distal portion of the extremity, with the possible formation of blebs. If unrelieved, paralysis quickly follows, asso- ciated with a marked shortening of the flexor muscles, resulting in acute flexion of the fingers which cannot be overcome by the appli- cation of any reasonable amount of force. Numbness and some- times complete sensory anesthesia are present, with thin glossy skin and atrophic nails. In the severest cases gangrene of the extremity may occur. At a later period the anesthesia and trophic disturbances may disappear, but the contraction of the muscles, which is due to connective-tissue change, is permanent. The features which serve to distinguish this condition from other forms of paralysis are the simul- taneous occurrence of the paralysis and contractions, and the inability to extend the fingers without flexion of the wrist. The prognosis in ischemic paralysis is generally unfavorable. Unless the condition can be relieved before six hours have elapsed, permanent damage results to the muscles. The treatment should consist in prompt removal of splints and tight bandages as soon as the condition is recognized. Fixation of the fractured bones should be disregarded for a time, and massage, pas- sive motion, hot and cold baths, electricity, and Bier's hyperemic treatment applied to restore the circulation and improve the nutrition of the muscles. At a later period if the anesthesia and trophic disturb- ances persist, the nerves should be exposed, freed from their fibrous beds, and transplanted to the subcutaneous tissue or surrounded by fat or Cargile membrane. Lengthening the flexor tendons or, better still, shortening the arm by a resection of from 2 to 4 cm. of the radius and ulna, occasionally has overcome deformity and enabled the shortened but not wholly degenerated flexor muscles to functionate. Fat-embolism is a plugging of the pulmonary capillaries with free fat-globules. The fat-globules are derived from the marrow, and are supposed to gain entrance to the blood current through the venous sinuses in the broken bone. They are first arrested in the capillaries and smallest arterioles of the lungs, but are occasionally found in the brain, kidneys, and other viscera. The symptoms are those of an exag- gerated shock, with rapid, labored respiration, and cyanosis. There also may be restlessness, delirium, and coma. The condition often is rapidly fatal, and is occasionally mistaken for pneumonia or delirium tremens. Delirium Tremens seems to follow fractures more frequently than other injuries of the same character, due possibly to the fact that the fracture frequently follows a state of intoxication, and the sudden 812 FRACTURES withdrawal of the alcohol after the injury gives rise to the symptoms. It is advisable under such circumstances to give a certain amount of alcohol, preferably ale, during the first few days after such an injury, and to combat the early restlessness and insomnia by generous doses of sodium bromide, digitalis, and chloral. Injuries of the veins may result in extensive extravasation of blood, forming hematomata, and these by pressure may cause edema or even gangrene. Occasionally arterial wounds give rise to traumatic aneurisms. Injury to the main arterial trunk of a limb may cause a rapidly advancing gangrene requiring amputation. The late complications of fracture are limitation of joint motion from intra-articular adhesions, misplaced bony fragments, connective- tissue changes in adjacent soft tissues, or exuberant callus; paralysis from laceration of a nerve trunk or from pressure of callus; muscular weakness from atrophy or adhesions between tendons and their sheaths; delayed union or non-union, which may be due simply to ill health or deficient blood supply, but is generally caused by faulty position of the fragments or the interposition of a layer of muscle or fascia between the broken ends of the bone; pseudarthrosis, when after non-union the ends of the bones become rounded and a kind of joint cavity is formed secreting serous fluid; and vicious union, a union of the frag- ments with deformity, giving rise to impairment of function. Treatment of Fractures in General. — In the treatment of fractures four principles should be observed: (1) To prevent further injury; (2) to reduce the displacement of fragments; (3) to maintain that re- duction; (4) to search for and treat associated injuries. In fractures of the lower extremity, skull, spine, or pelvis, or in the presence of other fractures complicated by shock or severe and painful contusions, the patient should be transferred to his home or a hospital on a stretcher. In removing him to and from the stretcher, the injured part should be carefully guarded by the surgeon or protected by an improvised splint, to prevent further injury of the soft parts. Fig. 376 illustrates an improvised pillow splint for fracture of the lower leg. If there is a wound of the soft parts and a probability of the fracture being compound, the wounded area should be immediately protected by an antiseptic pad, and later the entire limb shaved, scrubbed, and otherwise prepared as for a surgical operation. In simple fractures, after the diagnosis has been established by the methods mentioned above, in which the greatest care and gentle- ness must be observed to prevent further injury; the next step is reduction of the fracture, or, as it is usually spoken of by the laity, "setting the bone." This may be easily accomplished in superficially located bones, where there is little or no swelling or muscular rigidity by gentle traction and manipulation, the reduction being evidenced by disappearance of the deformity and a return to the normal of the outline of the limb. In many instances, however, accurate replace- TREATMENT OF FRACTURES IN GENERAL si:; ment is difficult, owing to swelling, great pain, muscular rigidity, and the difficulty of determining with precision the position of the frag- ments. In these and in all doubtful fractures, especially about the joints, general anesthesia should be used and the reduction accom- plished under the guidance of the .r-rays. The retention of the fragments in their normal positions after reduc- tion, while often easy, will occasionally tax the ingenuity of the sur- geon to the utmost. When the fractured bone is held in position by strong layers of muscle and fascia passing from a near and uninjured parallel bone, as in the case of fracture of a single rib or the fibula, practically no retention apparatus is required, the treatment being directed toward keeping the parts at rest. On the other hand, in fractures of the shaft of the femur, humerus, clavicle, or of both bones of the forearm*, even if once completely reduced, the bones are not infrequently misplaced by muscular action on the broken fragments after application of the splints. Fig. 376.— Pillow splint. In troublesome cases of this kind the .r-rays furnish us the most valuable aid, for by the constant use of the fluoroscope during the manipulations necessary to reduction and the application of the splints or other retention apparatus, every step of the operation can be controlled. Recently the writer was able to treat successfully in this manner an exceedingly obstinate case of fracture of both bones of the leg in which slipping of the fragments and marked displacement of the bones occurred no less than six times during the application of the plaster cast. Each time the deformity was recognized and cor- rected by use of the fluoroscope, although there was never any appar- ent deformity or change in outline observed in the soft parts. Almost any stiff material may be used for splints; thin strips of wood well padded may be placed on either side of a broken arm or leg and held in position by adhesive strips and bandages (Fig. 377); sheets of heavy pasteboard or gutta-percha may be softened in hot 814 FRACTURES water and moulded directly to the injured part and secured by band- ages; or, best of all, strips of crinoline thoroughly impregnated with plaster-of-Paris cream may be employed in the same manner. The latter has the advantage of hardening quickly while the injured mem- ber is being held in position. In applying any splint or retention Fig. 377. — Side splints. device the soft parts should be protected, especially over the seat of injury and in the neighborhood of bony prominences, by cotton pads. Care should be taken to avoid undue pressure, and a portion of the limb below the seat of injury should always be exposed, to enable the surgeon to watch the condition of the circulation. In all cases in which extensive contusions, edema, or ecchymoses exist, the dressings should be removed and the parts inspected frequently until all danger Fig. 378. — Fracture-box. of strangulation, sloughing, or gangrene has passed. In fractures of the lower leg accompanied by great swelling, severe bruising, ecchy- mosis, and the^formation of blebs on the skin, the fracture-box (Fig. 378) may be used, for it not only gives great relief to the patient by allowing the application of wet dressings, such as a solution of alumin- TREATMENT OF FRACTURES IN GENERAL 815 ium acetate or lead and opium wash, but it also enables the surgeon to inspect and treat every part of the injured leg without change of position or danger of disturbing the fragments. If there is little or no swelling, in simple fractures of the leg or forearm, a cast of plaster of Paris, dextrin, or starch, often can be im- mediately applied. This is particularly desirable if the patient exhibits the premonitory symptoms of delirium tremens. For plaster-of-Paris bandages, the best quality of dental plaster should be used. The plaster must be carefully protected from moisture, both before and after impregnating the crinoline rollers. To apply an encircling plaster cast to a member, the fracture should be properly reduced and the limb held firmly in position by an assistant. A thin layer of cotton or lint should first be evenly applied to the part. -This is accomplished best by the use of rollers made from sheet wadding, an exceedingly soft and delicate material which may be obtained in any dry-goods shop. After the limb is evenly Fig. 379. — Fenestrated plaster dressing. (Stimson.) covered by this material, several plaster-of-Paris rollers should be placed in warm water one at a time. The plaster rollers should then be applied to the limb, covering all parts evenly with from four to six or eight layers of the plaster-holding material. Where a light cast is desir- able, thin strips of splint wood may be inserted between the layers, and less plaster applied. If the fracture is compound, or if there exists a wound of the soft parts requiring a dressing, a window should be left or subsequently cut in the cast, freely exposing the wounded area which may then be dressed without removing the supporting cast (Fig. 379). This window should be carefully filled in with sufficient gauze or cotton to maintain pressure over this area equal to that exerted on the rest of the extremity. Unless this precaution is taken, the edema of the exposed portion will be annoying, and there may be a tendency to displacement of the underlying bone. In fractures of the long bones where there is a marked tendency to shortening of the limb and overriding of the fragments by the action 816 FRACTURES of strong muscles, this should be overcome by the use of some form of traction apparatus. Open Treatment of Fractures. — In a limited number of instances it will be necessary to obtain reduction by open operation. This should only be attempted under the most favorable circumstances. It requires special training, skilled assistants and a very careful technic, as the dangers from infection are greater here than in almost any other form of operation. It should be employed only when a satisfactory reduction cannot be obtained and maintained by the closed method. The operation is best performed from the fifth to the tenth day, according to the region involved. It is better to wait until the body has recovered somewhat from the original injury and has had an opportunity to marshal the forces of repair. It should be performed before the eighteenth day, as after that time the reparative tissue has become sufficiently organ- ized to make the details of the operation more difficult and accurate apposition less certain. In a majority of cases simple reduction of the displacement will be all that is necessary, when the reduction can be maintained by proper splinting or by bandaging in a suitable position. If there is any question of the fragments slipping out of place, however, it is wiser to use some internal means of maintaining the reduction. Simple suture of the periosteum with plain catgut may suffice. Occasionally chromic catgut, silk, linen, or wire will be necessary. Nails, screws, and bolts have their proper indications. The surest method of holding the fragments in place is by the use of metal plates, which are securely fastened to the bone on either side of the line of fracture by screws. The best form of plate is that made of vanadium steel as devised by Sherman. Plates made of ordinary steel, German silver, sheet aluminum, or celluloid are also used. Machine screws are prefer- able to wood screws in the shaft of a long bone, especially the fluted, self-tapping machine screws of Sherman. In the cancellous portion of bones, the wider flange of the wood screw often gives a better grip. The intramedullary dowel has almost entirely gone out of use, owing to the difficulty of insertion and also of later removal if this should prove necessary. The inlay bone graft of Albee is often indicated. After the frag- ments are properly reduced and the position maintained by holding clamps, a segment of bone is removed by a circular saw from each fragment, the one from the proximal end being twice the length of the other. The long segment is then moved up so that its centre is opposite the line of fracture. It is fastened in place by bone pegs made from the shorter segment. This work must be done very accur- ately and exactly. It is especially indicated in cases of delayed or non-union, where a stimulus to bone formation is needed. The inlay graft may be taken from another bone, preferably the tibia. In all open work on fractures the most careful technic must be TREATMENT OF FRACTURES IN GENERAL 817 observed. Nothing should be allowed to enter the wound that has been touched, even by gloved hands. x\ll the manipulations must be carried out with instruments. The after splinting should be carried out with as much care and for even a longer period of time than after a closed reduction. Firm union is not obtained as quickly after an open reduction as it is where an equally exact apposition has been obtained by the closed method. Compound Fractures. — While deformity and loss of function are the common results of unskilful treatment in simple fractures, pro- longed illness, loss of a limb, or death from sepsis, may be the out- come of unskilful treatment in compound fractures. In addition to the indications present in the treatment of simple fractures, we must, in the case of compound fractures, seek to prevent or overcome septic infection of the wound. In fractures by indirect violence, when there is little injury to the soft parts, and the opening leading to the bone is small, due to the projection outward of a small splinter of bone which has not penetrated the clothing, careful cleansing of the surrounding skin with gentle swabbing of the wound with tincture of iodine, and the application of a sterile dressing are recommended by most surgeons, in the hope that infection has not taken place, and that the injury may thereby be quickly converted into a simple fracture. In fractures by direct violence or where the end of the bone has penetrated the skin to a greater extent or come in contact with the clothing or other unsterile material, it is safer to explore and drain the region of the fracture. This should be done under general anesthesia; the limb should be shaved, scrubbed, and otherwise prepared as for a strictly aseptic operation. The wound should then be sufficiently enlarged to allow thorough inspection of the line of fracture; all evidently devitalized tissue should next be removed and the cavity swabbed with tincture of iodine. A 1 to 50 solution of formalin or hydro- gen peroxide is often of value in wounds which are already inflamed and foul, the latter serving also to arrest troublesome oozing of blood. The wound can then be partly closed, thorough drainage being pro- vided by gauze packing or rubber tubes, a sterile dressing and a suit- able retaining apparatus applied. When there is a tendency to separa- tion of the fragments they sometimes can be held together by a suture of chromicized catgut but no formal operation to obtain reduction, which necessitates baring additional surfaces of bone or opening new routes for spread of infection, should be attempted in the early days of a compound fracture. The surgeon must be satisfied with the establishment of free drainage with as little added trauma as possible. The fenestrated plaster cast or wire splint, allowing free access to the wound and drainage openings, will be found useful if there is reason to believe that the wound is badly infected and will require an early change of dressing. In cases in which the wound is small and in which little or no infection is suspected, a circular plaster cast may be applied, and the dressings allowed to remain in place for several 52 818 FRACTURES weeks. If it is found impossible to maintain a satisfactory reduction by careful splinting and traction, it is often wise to operate later, obtain a proper reduction and maintain it by suture or plating. This, however, should not be done until the infection has become limited and the resisting forces of the tissues well organized. It is often pos- sible to approach the site of fracture through tissue uninjured by the original trauma, apply the plate and close the wound completely, leaving the original wound as a drainage route. Plates and screws used in such compound fractures should always be removed after there is sufficient union to make their further presence unnecessary. In cases in which the infection spreads widely and is not controlled by the ordinary methods, wider incisions and freer drainage may i 1 r ■ ; , 1* 'fiK ( i 1 * I i fell i I ii A 1 A H HI *^up^ n 1 flu 1 1 \ i_ ii ■BMB 2 Fig. 380. — Instruments used in operative treatment of fractures. 1, sharp hook; 2 and 3, Lane elevators; 4, Lane holding clamps; 5, 6, and 7, Lambotte holding clamps; 8, Lane saw edged elevator; 9, drill; 10, Gerster turnbuckle; 11. elevator. sometimes be successful. Under these conditions the continuous warm bath has often proved useful, the solution used being mercuric chloride (-1 to 100,000) or carbolic acid (1 to 1000). Amputation should be promptly resorted to in cases in which an acute osteomyelitis develops, and in which the life of the patient is in danger from general sepsis. Delayed union or non-union generally is the result of faulty position, the interposition of a layer of muscle or other soft tissue between the fragments or infection in compound cases. It occasionally happens that the reparative powers of the individual are so reduced that callous formation does not take place even if the position of the bones is correct. Massage, with moderate irritation of the fragments by fric- tion, will often excite an inflammatory reaction and stimulate repair. Bier and Schmieden, believing that callous formation bears a direct TREATMEXT OF FRACTURES IN GENERAL 819 relation to the amount of extravasated bl 1. advise the injection between and about the fragments of from 30 to 40 c.c. of fresh venous blood drawn from the patient's arm. This to be repeated at intervals FlG 3 si_ii 12 and 13, Sherman vanadium steel plates, straight: 1-4, same, amded- 15 and" 16. Sherman bolts; 17, IS, and 19, Sherman fluted machine screws, S-tappin*: 20, round head wood screw; 21, flat head wood screw: 22. machine screw; 23, Sherman-Pierce combination screw holder and driver; 24, screw driver alone. of ten days or two weeks. If failure then persists open operation, fresh- ening the ends of the bone and correct apposition, maintained, if necessary, by sutures, nails, medullary dowels, inlay graft or metal plates is the treatment to be followed. 820 FRACTURES Visceral injuries, caused by fragments of bone penetrating the cranial, thoracic, or abdominal cavities, lacerating or causing pressure on the contained organs, call for immediate surgical relief. Injuries to adjacent nerves, bloodvessels, or ligaments must be sought for and repaired early when necessary. Massage is often of the greatest value in developing an increase in the circulation of the injured part, and thereby preventing marked atrophy of the muscles and causing rapid absorption of the inflam- matory exudates. Its use also favors nature's processes of repair and prevents stiffness of the joints and tendons. It may be employed as soon as the limb can be handled without displacing the fragments, and should be applied regularly every day. Local heat undoubtedly aids in the late repair. Daily baking (dry heat 250° to 300° F.), soaking the part in hot water for fifteen or twenty minutes several times a day, or the use of an electric pad are all satisfactory methods of obtaining local heat. Passive motion, unless carried out with extreme gentleness, may do far more harm than good. If carried beyond the point of moderate discomfort the added trauma is followed by a reaction on the part of the tissues which only adds to the impairment of function and delays complete recovery. Only when actual ankylosis exists can " breaking up adhesions" under an anesthetic be countenanced. Active motion, on the other hand, should be encouraged from the earliest period. Any movement of the adjacent joints which does not endanger the position of the fragments is allowed and urged after the first twenty-four hours. For example, after a Colles' fracture, the patient should be instructed to use the fingers, elbow, and shoulder frequently up to the point of pain or overtire. The wrist-joint, how- ever, must be immobilized until actual bony union is well under way. The general health of the individual should also receive attention, and phosphate of calcium or the syrup of hypophosphites should be given if union is apparently delayed from lowered vitality. In the aged it must be remembered that long continuance of the recumbent position favors hypostatic congestion and pneumonia, and an effort should be made to employ apparatus which will allow the patient to assume a sitting posture as soon as possible. This is especially important if there is a chronic bronchitis or emphysema present. FRACTURES OF THE SKULL. See Chapter XV. FRACTURES OF THE FACE BONES. Nasal Bones. — Fractures of the nasal bones are usually due to direct violence. The fragments are generally displaced laterally or are driven FRACTURES OF THE FACE BOXES 821 inward. The line of fracture may extend to the superior maxilla or lachrymal hones, and involve the tear duct. Symptoms.- -The symptoms are deformity, swelling, and ecchymosis of the overlying soft parts, and bleeding from the nose. Mobility and crepitus may be obtained by palpation; obstruction to nasal respira- tion is occasionally present from deflection of the cartilaginous septum or swelling of the mucous membrane. Efforts to blow the nose may result in extensive swelling of the surrounding parts and emphysema. Treatment. — The treatment should consist in early replacement of the fragments, as the tendency to rapid union is marked. If consid- erable deformity exists, an anesthetic should be administered and the fragments moulded into place by the fingers alone or by the fingers aided by some blunt instrument introduced within the nostril. Long curved forceps with rubber tubing over each blade are very useful in handling the fragments. With one blade in the nostril and the other outside a firm grip can be obtained and the pieces moulded into shape. Displacements of the septum can be corrected by use of the Adam- forceps (Fig. 382). If the fragments are properly reduced they will Fig. 382. — Adams forceps. stay in position unless disturbed. Pads and adhesive plaster are of very doubtful value, except to call attention to the injury. Gutta- percha plates moulded to the nose may be of service to protect against further injury. Packing the nose may be necessary to arrest hemor- rhage, but is rarely necessary to support the fragments. Malar Bone and Zygoma. — Fractures of the malar bone and zygoma are rare, generally due to direct violence, and are often accompanied by fracture of the superior maxilla. They are recognized by the deformity, localized tenderness, mobility, and crepitus. In fractures of the zygoma the bone is usually displaced, and there are pain and difficulty in opening and closing, the mouth, owing to the traction of the masseter muscle and the contact of the depressed fragment of bone with the coronoid process or temporal muscle. Replacement under these conditions may be difficult, and accom- plished only by an external incision and drawing the fragment forward with a hook. The hook can be introduced through a very small incision and depression and rotation easily overcome. Opening the antrum from within the mouth and pressing the bone into place is a more risky procedure and it may lead to antrum infec- 822 FRACTURES tion. Sometimes, however, these procedures are unnecessary, as a sufficiently accurate replacement can be effected by manipulation. Superior Maxilla. — Fractures of the superior maxilla are practic- ally always the result of direct violence. The processes are more often involved than the body of the bone; the fracture may involve the antrum, and is generally associated with other injuries. Symptoms. — The symptoms are pain on motion, bleeding from the mouth or nose, bruising and ecchymosis of cheek and lips, abnormal mobility, and crepitus. Emphysema may follow an attempt to blow the nose. Treatment. — The broken fragments should be replaced and held in position by wiring the teeth, by an interdental splint, or by direct suture with chromicized catgut or silver wire. If there is a tendency to displacement of the fragments, the jaw should be kept closed by a four-tailed bandange (Fig. 61) and liquid food only administered through a tube. When the mucous membrane of the mouth is torn in these and in fractures of the lower jaw infection is always present, giving rise to a foul, purulent discharge and an extremely offensive odor to the breath. To minimize the discomfort arising from this, the mouth should be frequently cleansed with hydrogen peroxide and other astringent and antiseptic solutions. Lower Jaw. — Fractures of the lower jaw are comparatively common in males of middle age, generally due to blows or falls; the commonest location of the break is at or near the canine tooth. Two or more fractures may occur. Fractures limited to the alveolar process or of the condyloid or coronoid processes are rare. These fractures, when involving the horizontal ramus, are probably always compound, communicating with the oral cavity. Symptoms. — In s'ngle fracture of the horizontal ramus the deform- ity is slight, easily appreciated, and readily reduced. In fracture involving the coronoid process the upper fragment is drawn upward by the temporal muscle. In fractures of the condyloid process there are pain on moving the jaw, a lateral dev'ation of the chin toward the affected side, and displacement of the condyle upward and forward by traction of the external pterygoid. In double fracture, on either side of the symphysis, the intervening fragment is drawn backward by the action of the hyoid muscles. The horizontal ramus is so easily palpated through the mouth that diagnosis in fractures of this part of the bone presents no difficulties. In fractures above the angle the diagnosis must be made from the characteristic deformity and finding a point of localized tenderness, abnormal mobility, and crepitus. Treatment. — The treatment of a single transverse fracture through the horizontal ramus is comparatively simple. In many cases all that is necessary is to keep the part at rest after reduction of the deform- ity. This is accomplished best by making an interdental splint of gutta-percha (Fig. 383), and keeping the jaws closed upon it by means of a four-tailed bandage. If there is a marked tendency to displace- FRACTURES OF THE BOXES OF THE TRUNK 823 nu'iit of the fragments owing to obliquity of the line of fracture or the presence of two or more fractures, the fragments can often be firmly held by wiring the teeth together on either side of the break, or, better, by direct union of the fragments with silver wire or chromicized catgut. As in fracture- of the upper jaw, especial eare should he taken to keep the mouth disinfected. Not infrequently a localized osteomyelitis follows fracture of the jaws, requiring subsequent operation. Fig. 383.— Gunning's interdental splint, with opening for introducing food. FRACTURES OF THE BONES OF THE TRUNK. Sternum.— Fractures of the sternum are comparatively rare. They occur mostly in middle-aged males, from direct violence or severe crushing injuries, and are generally accompanied by fractures of the ribs. The line of fracture is usually transverse, and its commonest seat is at the junction of the manubrium with the body of the bone opposite the second intercostal space. As union of these two portions of the bone is often delayed until old age, this injury is often a separa- tion of the two portions rather than a fracture. Fractures imme- diately above or below this point are more common than fracture at the lower part of the bone. Separations of the ensiform are occasion- ally encountered. In fracture or separation at the junction of the manubrium with the body of the bone the lower fragment generally lies above and sometimes overrides the upper. Longitudinal fractures have been observed. Compound and com- minuted fractures are exceedingly rare except in connection with gunshot wounds. In severe crushing traumata hemorrhage into the mediastinum and lesions of the thoracic viscera may complicate the injury. Diagnosis. — The diagnosis of this condition is comparatively easy in the absence of marked swelling of the overlying soft parts, the signs being irregularity in the outline of the bone, localized tender- ness, abnormal mobility, and crepitus. Spontaneous reduction fre- quently occurs. In these cases the only treatment necessary is the application of a firm binder, adhesive strips, or a plaster jacket. Y\ hen there is little or no tendency to displacement and no pain, simple rest in bed is all that is required. 82 \ FRACTURES Treatment. — If marked deformity exists from overriding of the fragments, reduction may offer difficulties. It is generally accom- plished by bending the body backward and exerting pressure over the projecting fragment while the patient takes a deep breath. If this does not succeed, reduction generally can be effected by an open operation under anesthesia, and replacement of the fragments by an elevator or hook, or by screwing a gimlet into the depressed fragment and drawing it into place. Ribs and Costal Cartilages. — Fractures of the ribs and costal carti- are of frequent occurrence. They are caused by direct violence, as ;i blow or fall upon the thorax; by indirect violence, as in a crush- ing injury; by muscular action, as in coughing or sneezing. The middle ribs are more frequently fractured than those nearer the upper and lower boundaries of the thorax. The injury may be limited to ;i -ingle rib, or many may be involved in the trauma. Under ordi- nary conditions the point of fracture is more often near the middle of the lone, and anterior to this point rather than posterior. Fracture near the bony and cartilaginous junction is not uncommon, and fracture of the costal cartilage is occasionally observed. When a single rib is fractured, there is, as a rule, no displacement, a- the muscular and fascial layers serve to hold it in place. When, however, several ribs are broken, these attachments are often torn, and there may be displacement with overriding. When the trauma i- -• were, the fragments may penetrate the pleura or lung, giving rise to pneumothorax, collapse of the lung, hemoptysis, and subcutaneous emphysema. In injuries of this character the pericardium and heart may also be wounded. Hemothorax from a wound of an intercostal artery may occur. Diagnosis. — The diagnosis of fracture of a rib is generally to be inferred if. after a blow or fall upon the chest, there is a point of local- ized tenderness, with acute pain on inspiration, coughing, or sneezing. Crepitus may often be elicited by palpation or heard with the stetho- scope. When several ribs are fractured, abnormal mobility and crepitus are easily obtained by palpating the region with the flat hand. Fractures of the ribs are rarely compound, except those produced by gunshot or other penetrating injuries. Prognosis. — The prognosis depends upon the visceral trauma. In a simple fracture of one or more ribs without involvement of the pleura recovery is rapid and uneventful. If the lung or other important structures are involved, the prognosis is necessarily more grave, depending upon the extent and character of the visceral involvement. Treatment— The treatment consists in rest, limitation of the move- ments of the chest-wall, and measures addressed to the pleural and pericardial complications if these are present. It is rarely necessary to reduce a fracture of a rib, as there is seldom marked displacement. If, however, a fragment is driven inward and remains a source of irri- tation to the pleura or lung, it should be properly reduced. When FRACTURES OF THE BONES OF THE TRUNK 825 this is not easily accomplished by manipulation and inspiratory efforts of the patient, replacement by a hook or elevator through an open wound may be necessary. Limitation of the thoracic movements will often promptly relieve tlie pain. This is accomplished best by a snugly fitting binder or by the application of adhesive plaster straps, always during expiration. The plaster straps should completely encircle the chest in order to obtain the proper immobilization. The Pelvis. — Fractures of the pelvis may occur from crushing injuries, from falls from a height upon the iliac crest, trochanter, sacrum, pubic symphysis, or feet; or from blows received in this region by some heavy object. These fractures are often accompanied by injury to the bloodvessels or some of the pelvic or abdominal viscera. The-e fractures may be conveniently divided into two groups: those which involve the integrity of the pelvic brim, and those which are limited to a part remote from the true pelvis. The former are far more serious in their results than the latter. In fractures of the pelvic ring the commonest seat is through the pubic rami, both horizontal and descending rami being often involved, as these are the weakest part- of the bony pelvis. Occasionally the fracture is bilateral, the symphysis being entirely separated and driven backward into the pelvic cavity. Vertical fractures of the ilium extending into the true pelvis often accompany fractures of the pubic arch. The acetabulum may be fissured by a fall upon the feet or trochanter, its rim broken, or the head of the femur may be driven through it> walls into the pelvis. Horizontal and vertical fractures of the sacrum occur in connection with other fractures of the pelvis, and a separation of the sacro-iliac joint may be produced under similar conditions. All of these fracture- involving the pelvic brim are likely to be associated with visceral injury. Those most frequently found are wounds of the urethra, rupture of the bladder, tears of the rectum, injuries to the iliac ves.-els, and lacerations of the intrapelvic portion of the ureter. Fractures of the iliac crest, coccyx, or other parts not involving the integrity of the pelvic brim, occur, but are not generally associated with injury of the viscera or vessels. Diagnosis. — The diagnosis is usually easy. There is a history of severe injury, followed by pain in the region of the pelvis, which is increased by any movement of the trunk or legs. Pressure over the iliac crests toward the median line will always elicit pain unless the fracture is limited to the coccyx, descending rami, or tuberosity of the ischium. Careful palpation of the pubic arch, iliac crests, sacral region, and of the interior of the pelvis by the rectum or vagina, will often serve to locate the seat of fracture. In fissures of the acetabulum the only symptom may be pain in the joint following a fall upon the feet or trochanter. This may be rendered acute by a blow upon the foot or knee. Fractures of the rim of the acetabulum are generally accompanied by dislocation of the head of the femur upward, which 826 FRACTURES is easily reduced by traction but readily recurs. When the head is driven into the pelvis, there is flattening of the hip, and the head of the bone may sometimes be felt by rectal examination. In severe cases, when there is a complicating visceral injury, the shock is often so great as to mask other symptoms. In urethral injuries we may have retention or extravasation of urine. Hematuria is present in wounds of the bladder or ureter. In extensive intraperitoneal wounds of the bladder the viscus may be empty, the catheter withdrawing only a small quantity of blood. Intermittent hematuria suggests a wound of the ureter. Rectal bleeding is present in wounds of that organ or the sigmoid colon. Wounds of the iliac vessels are indicated by the gradual development of a semisolid retroperitoneal pelvic tumor or by pallor, cold extremities, weak pulse, and other evidences of shock, when the hemorrhage is within the peritoneal cavity. Treatment. — The treatment in uncomplicated cases consists in the reduction of any deformity and the application of a dressing to secure immobility of the parts. The employment of a stout pelvic binder, or double plaster spica, is generally sufficient. Semiflexion of the thighs, the legs resting on one or two pillows placed under the knees, is a comfortable position for the patient. Tying the legs together may be necessary if the fragments are loose and easily displaced. If there is evidence of vesical injury or severe hemorrhage, laparotomy should be performed to locate the seat of the hematoma and to repair any intraperitoneal injury, after which the peritoneum should be closed and the prevesical space opened, clots removed, vessels secured, bladder wound repaired, and the displaced fragments of bone, if present, reduced and held by sutures. Generous drainage should be employed in the suprapubic wound, and the bladder drained by a perineal tube. In fractures of the tuberosities of the ischium, sacrum, or coccyx, no treatment is required other than rest, immobility, and the use of air cushions to prevent pressure on the loose fragments. In fracture of the rim of the acetabulum, extension, as in fractures of the femur, may serve to keep the head of the bone in the socket, although the prognosis is not favorable. FRACTURES OF THE BONES OF THE UPPER EXTREMITIES. Scapula. — Fractures of the scapula are comparatively rare. The portion of the bone most frequently broken is the acromion process; next in frequency come the body and spine; fractures of the neck, coracoid process, and glenoid fossa are rare. Acromion. — This fracture is generally transverse and situated just in front of the acromioclavicular articulation. It is due to a fall or blow on the shoulder, elbow, or hand, or to direct violence on the tip of the shoulder. Traumatic separation may take place at the epiphyseal line at any age, and it should be remembered that a failure FRACTURES OF BONES OF THE UPPER EXTREMITIES 827 of union of the epiphysis may occur which may lead to an error of diagnosis in a contusion of this region. The diagnosis is usually made by observing a slight flattening of the shoulder, localized tenderness, and irregularity of outline on passing the finger along the edges of the bone, crepitus and abnormal mobility on raising the arm and shoulder. Voluntary abduction of the arm is painful and often impossible. Bony union occurs only when the fragments are accurately replaced. This is often difficult to accomplish, and in the majority of instances the union is fibrous. Treatment. — The treatment consists in the application of a dressing which pushes the humerus w T ell upward and outward. The use of Moore's figure-of-eight bandage from the elbow to the opposite shoulder (Figs. 384 -and 385) perfectly fulfils this indication. If this fails to maintain close and accurate apposition of the fragments the site of fracture should be exposed by incision, and the bones united by tw r o sutures of silk or chromic catgut. A metal plate may be applied to the dorsal surface of the acromion and spine. This should be removed later because of its subcutaneous position. Body and Spine. — Fractures of the body of the bone. are generally due to direct violence. The line of fracture is commonly transverse; it may, however, be oblique or irregular, and occasionally assumes a longitudinal direction extending through the spine. Fractures of the supraspinous region are very rare. Isolated fracture of the spine is uncommon. Diagnosis. — The diagnosis is established by. direct palpation and by movements of the arm, revealing points of tenderness, irregularities in outline, mobility, and crepitus. Treatment. — The treatment consists in reduction by manipulation and movements of the arm, and retention by the application of adhesive plaster straps or a snugly fitting binder and sling, as seen in Figs. 59 and 60. Neck and Glenoid. — Fractures of the neck and glenoid are exceed- ingly rare. In the former the line of fracture may include the coracoid process or lie external to it; in the latter the fracture may be stellate. Epiphyseal separation of the neck, including the coracoid, is possible before the fourteenth year. Diagnosis. — In fractures of the neck the signs are those of a sub- glenoid dislocation: flattening of the shoulder, prominence of the acromion, and the presence of the head in the axilla. Reduction is easily accomplished by raising the humerus, but the deformity is at once reproduced when the support is removed. These movements give rise to crepitus. Treatment. — The treatment consists in reduction, which is easy, and retention of the fragments, which is difficult to accomplish. The application of Moore's figure-of-eight bandage (Figs. 384 and 385), or the sling and binder dressing, will be found useful. The writer on one 828 FRACTURES occasion obtained a satisfactory result by the immediate application of a plaster-of-Paris spica extending from the shoulder to the hand, the elbow Hexed across the chest, and the humerus being pushed firmly upward and held in this position until the plaster hardened. Coracoid. — Fractures of the coracoid process are generally due to direct violence, and are often associated with fracture of the clavicle or ribs. If the ligamentous attachments are ruptured, there may be a separation by action of the biceps, coracobrachialis, and pectoralis minor muscles. Fig. 38-1. — Moore's dressing for frac- tured clavicle. Front view. Fig. 385. — Moore's dressing for fractured clavicle. Rear view. Diagnosis. — The signs are pain on motion and localized tenderness; crepitus may be felt if the fragments are not w r idely separated. Union is generally fibrous, but without functional disturbance. Treatment. — The treatment should consist in the application of a Velpeau bandage (Fig. 53). If this fails to maintain sufficiently good apposition it may be necessary to expose the site of fracture and hold the fragments together by a long screw. Clavicle. — The clavicle is fractured more frequently than any other bone in the body. By far the larger number of cases occur in child- hood, although it is by no means infrequent in later life The seat of fracture is commonest at the outer portion of the middle third, where the line is usually oblique. Next in frequency fractures occur in the FRACTURES OF BONES OF THE UPPER EXTREMITIES 829 outer third. Here they are apt to be transverse, with little or no dis- placement except at the outer end, where displacement may be marked. Fractures near the sternal end are rare, as is a separation of the epiphy- sis. The commonest cause of this fracture is indirect violence, as ;i fall on the shoulder, elbow, or outstretched hand, the muscles being rigid (an application of force which in later life frequently results in a dislocation of the shoulder). Direct violence is responsible for a considerable number of these fractures, and muscular action has been recorded in a few. Indirect violence produces the fracture by exag- gerating the normal curves of the bone, which results in the oblique direction of the break. The inner fragment is pulled upward by the action of the sternomastoid muscle; the outer fragment falls down- ward and forward by the weight of the unsupported shoulder. Complications. — Complication in this fracture are rare. The fracture may be compound, double (generally in the middle third), or com- minuted. Occasionally the fragments are driven inward, injuring the trunks of the brachial plexus or subclavian vessels. In the former condition a more or less complete and persistent paralysis of motion or sensation may result from pressure or secondary neuritis; in the latter, extensive hematomata or arteriovenous aneurism may occur, requiring immediate or remote surgical treatment. Diagnosis. — The diagnosis of fracture of the clavicle is usually easy. The patient sits or stands with the head inclined toward the injured side, the shoulder lowered, and the elbow supported by the sound hand or resting upon the knee. All movements of the shoulder are painful. On palpation bony irregularity, localized tenderness, and crepitus can be readily appreciated. In transverse fractures of the outer third without displacement localized tenderness and pain on motion of the shoulder may be the only signs. In a fracture of the inner third the deformity may resemble a dislocation of the sternal extremity. Prognosis. — The prognosis in fracture of the clavicle is usually favorable, union taking place in the great majority of cases in from three to five weeks. There is, however, a certain amount of per- manent deformity in the majority of cases, due to shortening and over-riding of the fragments. Delayed union or failure of union may result from comminution and separation of the broken ends by bone fragments, clots, or shreds of tissue. Treatment. — The treatment, to be successful, must first effect a complete reduction of the deformity and then maintain the fragments in this position until union has occurred. This is by no means easy. Probably the best result could be obtained by keeping the patient in the dorsal recumbent posture with a small pillow between the shoulders, but this in the great majority of instances would be wholly imprac- ticable. As the chief deformity is due to the action of the sternomas- toid muscle in elevating the inner fragment, and to the dropping downward and inward of the shoulder and outer fragment, producing 830 FRACTURES an overriding, reduction is accomplished best by carrying the elbow backward and upward; this carries the outer fragment outward and upward, and at the same time renders tense the clavicular fibres of the pectoralis major, thereby opposing the action of the sternomastoid. This position is easily maintained by the application of Moore's figure-of-eight bandage from the elbow to the opposite shoulder (Figs. 384 and 385). This dressing, if properly applied and frequently inspected to prevent slipping from the shoulders and loosening, gives by far the best results of any apparatus or method of dressing known to the writer. Perhaps the dressing most frequently employed and, on the whole, the most desirable when the patient cannot be frequently Fig. 386. — Sayre's adhesive plaster dress- ing for fractured clavicle. Front view. Fig. 387. — Sayre's adhesive plaster dressing for fractured clavicle. Rear seen and examined, is the Sayre dressing shown in Figs. 38fi and 387, which consists of two strips of adhesive plaster, one encircling the arm about its middle and carried backward around the body, the other passed around the elbow and opposite shoulder. The first acts as a fulcrum; the second, by drawing the elbow forward and upward, forces the shoulder upward and backward. In applying this it is very important to use plenty of padding under the plaster encircling the arm, especially along its upper edge. The Velpeau bandage has also been extensively employed, but as it always tends to increase the deformity it is not to be recom- FRACTURES OF BONES OF THE UPPER EXTREMITIES 831 mended. When the conditions are such that some measure of defor- mity cannot be avoided, the simple sling and body-binder will be found useful (Figs. 59 and 60). Union with deformity or delayed union can be successfully treated by an open operation, accurate reduction, and suture of the fragments with chromicized catgut or the application of a metal plate. In fractures of the outer third the presence of marked displacement means that the coracoclavicular ligament has been either ruptured or torn from its attachments. This will be shown in the arrays by the increased distance between the coracoid and the clavicle. When this occurs the ligament must be repaired either by suture of its fibres or by passing a heavy-braided silk cord over the clavicle and under the coracoid. Humerus. — Fractures of the humerus are less frequent than fractures of the clavicle or forearm, and are conveniently divided into three main groups: fractures of the upper extremity, shaft, and lower extremity. Fractures of the Upper Extremity of the Humerus include those of the anatomic neck, intracapsular, above the tuberosities, which are very rare; those of one or both tuberosities, associated with a line of fracture through the anatomic neck, somewhat more frequent; those of the greater or lesser tuberosity alone, rare, and generally associated with dislocation; those of the surgical neck, which include all of those lying above the attachment of the pectoralis and teres major and below the epiphyseal line, and which constitute by far the greater number of fractures of the upper extremity of the bone; and separa- tions of the upper epiphysis, which may occur before the twentieth year. Fractures of the anatomic neck, with or without involvement of the tuberosities, are generally due to falls or blows on the shoulder; those of the surgical neck may be produced by direct violence, by falls upon the elbow, or by cross-strain, the arm being fixed by muscular action, the injury generally taking place on the outer side of the bone, or by forcible rotation of the bone. Diagnosis. — This in fractures of the anatomic neck may be impos- sible without .r-ray examination, as no deformity exists, and the only sign may be pain in the joint increased by motion (Stimson). Fracture of the anatomic neck, however, may be assumed when there are pain and crepitus high up in the joint without deformity, when the tuber- osities rotate with the shaft, and when fracture of the glenoid, coracoid, or acromion can be excluded. If tenderness over the tuberosities exists, crepitus, and an evident thickening of the bone in this region, fracture of the anatomic neck involving one or both tuberosities may be assumed; if no crepitus can be obtained and there is a slight shortening, the fracture is probably impacted. In fracture of the greater tuberosity alone there are localized tender- ness and pain on outward rotation. It is generally associated with dislocation of the head. 832 FRACTURES In fracture through the surgical neck the deformity is usually characteristic; there is angular deformity of the arm just below the point of the shoulder with deviation inward of the axis of the arm, caused by the drawing inward of the lower fragment by the pectoralis major, and the slight flexion and rotation outward of the upper frag- ment by the muscles attached to the tuberosities. The lower portion of the arm is usually abducted and supported by the opposite hand of the patient. The shoulder is lowered, but not flattened as in dis- location, and the acromion is not prominent. Localized pain and crepitus are easily obtained by palpation at the point of injury while gently rotating the bone from below, and this rotary motion is not shared by the tuberosities, unless the fragments are impacted. Shortening is usually noticeable from drawing upward of the lower fragment, the point of which can often be felt under the skin in the axilla or, rarely, under the coracoid. Dislocation can be positively excluded by feeling the head of the bone in place, by a fulness instead of a flattening just below the acromion, and by placing the hand on the opposite shoulder and noting that the elbow can easily be made to touch the wall of the thorax. Complications. — Injury to the large vessels and nerve trunks of the axilla by the sharp lower fragment of bone has been reported, giving rise to more or less extensive circulatory, motor, and sensory disturbances of the arm, the latter due to direct injury of the nerves, to a subsequent neuritis, or involvement of the nerve in the callus. The association of fracture in this region with dislocation or with injury to other neighboring bones may render the diagnosis obscure and present many difficulties in treatment. Prognosis. — In the absence of complications fracture at the upper extremity of the humerus is an injury in which a good functional result may be expected, bony union taking place in the majority of instances in which satisfactory reduction has been effected. Exu- berant callus and bony outgrowths may occur occasionally, especially in fractures involving the tuberosities, and may give rise to permanent limitation of motion. Treatment. — In all doubtful cases general anesthesia should be induced and a careful examination made. In fracture of the anatomic neck without displacement all that is necessary is to immobilize the arm and protect the parts from further injury. This is accomplished best by the use of the sling and body-binder, as shown in Figs. 59 and 60. If there is displacement, as shown by the .r-rays, the arm should be immobilized in that position which best approximates the fracture surfaces. This will usually be in abduction. Fractures through the tuberosities, if impacted, should be left undisturbed if motion of the joint is not hindered, and may be treated by the same simple method, or by the internal angular splint with or without a shoulder-cap. With separation of the fragments immo- bilization in abduction may maintain apposition. If this is not sue- FRACTURES OF BONES OF THE UPPER EXTREMITIES 833 cessful open reduction with suture or nailing is indicated. Fractures through the surgical neck, high up, may present little or no displace- ment, and be treated similarly, but in the great majority of instances fractures of the surgical neck require for their treatment some appara- tus which combines extension with a firm grasp of the fragments, together with fixation of the shoulder- and elbow-joints. In the writer's experience these conditions are fulfilled best by the use of a plaster-of-Paris spica extending from the shoulder to the wrist, the elbow being flexed at a right angle (Fig. 388). The method of applica- tion is as follows: Two strips of adhesive plaster are placed longitudi- Fig. 388. — Plaster spica, arm and shoulder. nally on either side of the lower half of the upper arm, the ends hang- ing free below the elbow. The upper part of the thorax, shoulder, and arm are next enveloped in two or more layers of sheet wadding; firm extension is then made by an assistant on the traction straps to overcome shortening, and the plaster rollers are applied in the usual manner. Extension is maintained until the plaster is hardened. This dressing is applicable to all fractures of the humerus in which a tendency to recurrence of the deformity is present. In epiphyseal separation of the upper extremity of the humerus the deformity is characteristic, owing to the projection of the anterior sharp margin of the lower fragment an inch below the acromion, 53 s:;4 FRACTURES the posterior margin of the shaft being lodged in the concavity of the upper fragment (Figs. 389 and 390). Reduction of the deformity is accomplished best by raising the arm anteriorly above the head (Moore), after which the fragments are kept in place by the plaster- of-Paris spica, the arm being elevated and abducted to forty-five degrees. It occasionally happens in fractures about the shoulder-joint, particularly in epiphyseal separations, and in fractures complicated by dislocation of the head, that open operation is to be recommended when the ordinary methods of manipulation fail to effect reduction. The region of the joint is best exposed by a curved incision extending from the tip of the coracoid outward and downward for four or five inches and deepened to the deltoid muscle. This flap is then dissected Fig. 389. — Upper epiphysis of the humerus at ten years; separated by maceration. Outer side. (Moore.) Fig. 390. — Separation of the upper epiphysis of the humerus; displacement forward of the lower fragment. (Moore.) iij) and the deltoid separated from the pectoralis major, avoiding the cephalic vein. If necessary to obtain additional room the anterior fibres of the deltoid are cut transversely a half-inch from their clavic- ular attachment and the muscle flap turned outward. If the deltoid is split the nerve supply to the anterior fibres is destroyed and this portion will atrophy. Fractures of the Shaft of the Humerus are quite common, and are due to direct and indirect violence and to muscular action, the latter cause being more frequently observed in this fracture than in fracture of other long bones. The line of fracture may a>sume almost any direction, but is more commonly transverse. Displacement is often considerable, and extensive injury to the soft parts is frequent, with occasional lesion of FRACTURES OF BOXES OF THE UPPER EXTREMITIES 835 the musculospiral nerve and larger bloodvessels. Delayed union and failure of the hone to unite are more frequently ohserved in fractures near the middle of the humerus than in any other hone of the body, due to separation of the fragments by strips of muscle or fascia, or to imperfect immobilization of the parts. This fact and the possibility of paralysis from musculospiral nerve injury should always be remem- bered in making a prognosis. Diagnosis. — The diagnosis is easily made, as deformity, abnormal mobility, and crepitus are readily appreciated. Treatment. — Reduction should be effected and the fragments held in place by a plaster-of-Paris spica from the shoulder to the wrist, the elbow being flexed across the body (Fig. 388). The use of an external plaster- of-Paris splint moulded over the shoulder and extending to the hand is lighter and often quite as serviceable. Internal angular splints alone are to be condemned, as they always allow a certain amount of motion between the fragments. If reduction cannot be maintained in this way, if muscular interposition is suspected because of lack of crepitus at the time of reduction, or if there is any evidence of musculospiral involvement, an open reduction is indicated and usually the application of a metal plate. The best route for the middle third is between the outer and middle heads of the triceps. The treatment of compound fractures in this region differs in no respect from those of other long bones. Fractures of the Lower Extremity of the Humerus. — Fractures of the lower extremity of the humerus are divided into five classes: transverse fractures above the condyles; T-fractures into the joint; fractures of the external condyle; fractures of the internal condyle; and epiphyseal separations. In all of these varieties of fracture the cause is direct or indirect violence, generally falls or blows upon the hand or elbow. They are more frequent in children than in adults. Diagnosis. — In fracture above the condyles the direction is generally transverse from side to side, but oblique from above and behind downward and forward. The lower fragment is drawn backward and upward by the action of the triceps, and the upper fragment projects downward, making a prominence in front, just above the joint-line. This backward displacement of the lower fragment creates a deformity somewhat resembling that produced by a backward dislocation at the elbow. The points in differential diagnosis are: The normal relations of the epicondyles and olecranon, ease of reduction, tendency to a return of the deformity, the projection in front of the joint above the joint-line being rough and irregular, and the presence of crepitus. An anterior or lateral displacement of the lower fragment may occur, giving rise to atypical deformities (Fig. 391). In the T-fracture, in addition to the transverse line of fracture above the condyles, there is a line of separation extending from this to the articular surface ( Fig. 392). As this fracture involves the joint, there is, in addition to the signs of the supracondyloid fracture, an s::ii FRACTURES Fig. 391. — Supracondyloid fracture. Fig. 392. — T-fracture of humerus. (Helferich.) (Stimson.) Fig. 393. — Four years. 1 Fig. 394. — Six years. 1 Figs. 393, 394, 395, 396, 397, 398. — Epiphyseal development of the lower end^of the humerus. FRACTURES OF BONES OF THE UPPER EXTREMITIES 837 Fig. 395. — Nine years. Fig. 396. — Eleven years. Fig. 397. — Fourteen years. Fig. 398. — Seventeen years. 838 FRACTURES increase in distance between the two epicondyles, separate mobility of each condyle, and an effusion into the synovial cavity. In fractures of the external condyle the line of fracture may be wholly external to the joint (fracture of the epicondyle), or it may pass obliquely into the joint from a point just above the epicondyle, or from a point just below the epicondyle (capitellar fracture). The same is true of fractures of the internal condyle. In the former the diagnostic points are pain on motion, tenderness over the outer side of the joint, separate mobility of the external condyle, crepitus, and a tendency to abduction of the forearm. In the latter the same signs are present on the inner aspect of the elbow and a tendency toward adduction of the forearm. If the displacement is slight, the relation of the epicondyles and olecranon may not be altered; generally, however, the fractured epicondyle is somewhat higher than its fellow, and in the case of the internal condyle there is often a displacement backward due to the upward traction of the ulna by the triceps. Epiphyseal separations are rare, occur at an early age, and generally consist in a separation of the articular surface below the epicondyles. (Fractures of the articular surface have also been reported in later life.) As these fractures lie within the capsule of the joint the tendency to marked deformity is slight. The signs are slight backward displace- ment, which is easily corrected, and is as easily reproduced; muffled crepitus, and finding the epicondyles attached to the shaft of the bone. A study of the development of the lower extremity of the bone, as described by Henle and illustrated in Figs. 393 to 398, will show that in very early life a separation may occur which will include the epicondyles in the lower fragment. At a later period the line of separation must be below the internal epicondyle, but may be above the external epicondyle. It is not improbable that in many of the injuries described as fractures of the external condyle occurring before the seventeenth year the lesion is a separation through the cartilage connecting the shaft with the ossified epicondyle and capitellum. Complications. — Fractures at the lower end of the humerus are rarely compound. They are occasionally comminuted, and not infrequently are accompanied by injury to the ulnar or musculospiral nerve, the former more commonly in fracture of the internal condyle, the latter in those of the external condyle. Treatment. — In all of these fractures the diagnosis should be verified by an examination under general anesthesia and with the .r-rays. Reduction is generally easy, but difficult to maintain. In transverse fractures, supracondyloid and epiphyseal, reduction is accomplished by traction in a hyperextended position, followed by acute flexion. In T-fractures and fractures of the internal or external condyle Cotton advises dressing the arm in an acutely flexed position. This position, with pressure on the epicondyles, serves to reduce the fracture, and should be maintained by a strip of zinc oxide FRACTURES OF BONES OF THE UPPER EXTREMITIES 839 plaster passed around the wrist and upper part of the arm (Fig. 399). The flexed arm is then placed snugly against the lateral chest wall on a gauze pad, and held in place by a broad bandage of folded muslin applied as shown in Fig. 400. If the forearm is placed across the anterior chest wall the lower fragment is rotated inward on the shaft and tends toward a rotatory displacement. The use of a plaster-of-Paris bandage extending from the shoulder to the wrist has many advantages, especially in young children. In any case it is desirable after the application of the dressing to examine the parts with the x-rays. Fig. 399. — Arm dressed in the acutely flexed position. First stage. Fig. 400. — Arm dressed in the acutely flexed position. Second stage. When reduction is perfect, union is rapid, and if the joint is not involved, a good functional result may be expected. In all fractures extending into the joint passive motion should be practised early and persistently but very gently. It may be commenced at the end of two weeks, should be employed every other day at first, and later every day if there is much limitation of motion. The combination of motion and massage will be found useful in most cases. Limitation of motion at the elbow after fracture is generally due to mechanical obstruction from misplaced fragments, to a deposit of callus in the 840 FRACTURES olecranon or coronoid fossa, to fibrous thickening of the fat pads in these fossae, or to inflammatory adhesions in the joint. Considering the frequency of these complications, the prognosis in every case should be guarded. Operative treatment of fractures of the lower end of the humerus may be necessary, to effect reduction of the fragments when, for any reason, such reduction cannot be brought about by the ordinary non-operative methods; to remove non-viable fragments of bone; to relieve nerve pressure or to increase the range of motion after vicious union has occurred. The best route is the anteroexternal. The internal margin of the brachioradial muscle (supinator longus) is identified and this separated from the brachialis anticus. After the musculospiral nerve is identified the fibers of the brachialis anticus are split a half-inch internal to the nerve and the bone thus exposed. For high supracondylar fractures the posterior route, splitting the triceps, may be preferable, especially if a plate has to be applied. When the seat of fracture is exposed the bones should be accurately readjusted, and held in place by sutures of chromic gut, screws, nails, bolts, or metal plates, or simply by the position of the extremity. The wound should then be closed, without drainage, and a plaster- of-Paris cast applied. Motion should be commenced as early as the third week, and massage as soon as the fragments have sufficiently united to prevent easy displacement. Fractures of the Forearm. — Fractures of the forearm are commonly divided into those occurring near the elbow, those occurring in the shaft of one or both bones, and those occurring near the wrist-joint. Fractures in the neighborhood of the elbow-joint are those of the olecranon, coronoid process, and of the head and neck of the radius. Fractures of the Olecranon. — Fractures of the olecranon are of comparatively frequent occurrence. They result commonly from falls or blows on the elbow, from muscular strain, or from both causes combined. If the fracture occurs near the shaft of the bone, there may be only a slight separation, the fragment being held in place by the muscular and aponeurotic attachments. Generally, however, the detached fragment is drawn upward by the triceps, and a distinct sulcus is present which can easily be appreciated by the examining finger. Diagnosis. — The diagnosis is established by the presence of localized pain and tenderness, abnormal mobility of the separated fragment, swelling of the joint, and inability to extend the forearm fully. Crep- itus is generally absent, owing to separation of the fragments. Treatment, — The treatment consists in fixation of the arm in a partially extended position. As complete extension is more or less uncomfortable to most patients, a slight flexion to 15 or 20 degrees may be allowed. All attempts by bandages or adhesive straps to overcome the powerful action of the triceps muscle in drawing the loose fragment upward are useless, and only serve to constrict the soft FRACTURES OF BONES OF THE UPPER EXTREMITIES 841 parts and favor edema. If any appreciable degree of separation is present, the union is always fibrous, and the separation of the fragments may be inereased by the later use of the arm. For this reason it is wiser to expose the site of injury by a U-shaped incision, remove the blood clots from the joint and hold the fragments in apposition by an encircling suture of heavy silk or chromic gut. This should pierce the triceps insertion transversely above and pass through a hole drilled in the ulnar shaft below. Fractures of the Coronoid Process. — Fractures of the coronoid process are rare and almost always associated with a backward dislocation of both bones. Symptoms. — The symptoms characteristic of this condition are: A backward dislocation at the elbow, which is reduced with more than ordinary ease, but -in which a tendency to redislocation is marked, and the presence of a small fragment of bone in front of the joint, drawn upward by the action of the brachialis anticus muscle. Crepitus is rarely obtained except in the position of extreme flexion. Treatment. — The treatment of this fracture consists in reduction of the dislocation and immobilizing the arm in a flexed position, the degree of flexion necessary being determined by the point at which crepitus can be obtained, generally somewhat more than a right angle. If this position fails to obtain sufficient approximation as shown by the .r-rays, the coronoid may be exposed through an antero-external incision and held in place by a long screw or suture. Fractures of the Upper Extremity of the Radius. — Fractures of the upper extremity of the radius may be limited to the head, stellate fissures or complete separation of a fragment; or they may involve the neck cf the bone, in which case they are generally transverse and usually impacted. »They may occur as a result of direct violence, usually a fall or blow on the outer aspect of the elbow or indirectly from a fall on the extended hand, the elbow being in full extension. They are occasionally associated with a dislocation. Diagnosis. — The diagnosis is often uncertain unless confirmed by a radiograph or incision. The symptoms suggesting the lesion are pain, localized tenderness, and occasionally crepitus on pronation and supination, without marked deformity. Marked limitation of flexion pronation, and supination may be occasioned by the presence of a loose fragment of the bone in the joint cavity. Treatment. — If the fragment lies in front of the lower humeral surface where it will interfere with flexion, the treatment should be open incision, thorough inspection, and removal of any fragment of bone. Excision of the head of the bone may be required if there is much comminution and displacement of the fragments. The incision which best exposes this portion of the joint is the posterolateral curved one between the anconeus and extensor carpi ulnaris. If no deformity exists and little or no limitation of the normal movements, fixation of the elbow at a right angle is all that is recpiired 842 FRACTURES in the way of treatment. The amount of displacement rather than the extent of the fracture should he the guide for operation. As in all fractures involving the elbow-joint, early massage and passive motion are essential. Fractures of the Shaft of One or Both Bones. — Fractures of the shaft of one or both bones of the forearm are of frequent occurrence, and may be produced by direct or indirect violence. Fractures of the ulna alone are slightly more frequent than those of the radius alone, and are almost always produced by direct violence, as a blow upon the outer aspect of the arm as when that member is raised to guard the face in boxing. Fractures of the shaft of the radius are often the result of direct violence, but are more generally produced by indirect violence, as a fall on the hand. Muscular action alone is rarely responsible for these fractures. When the ulna alone is broken the displacement is often slight, unless the injury is complicated by a dislocation of the head of the radius, in which event the displacement may be con- siderable, and its direction is more influenced by the fracturing force than by the action of muscles. In fractures of the radius above the insertion of the pronator radii teres muscle the upper fragment is drawn upward and outward by the biceps and strongly supinated by the same muscle and the supinator brevis; in fractures below that point the tendency of the fragments is toward the ulna, the upper one being often drawn upward by biceps influence. In fractures of both bones almost any variety of displacement may be present, the fracturing force being, as a rule, a more potent agent in its production than action of the muscles. Diagnosis. — Fractures of the forearm occurring in the shafts of the bones are more readily recognized than those at either extren ity. If both bones are fractured, there is, as a rule, considerable angular deformity of the forearm, either present or easily produced; localized tenderness, false motion, and crepitus are easily elicited, and shortening is generally present. In fractures of the radius alone some deformity is often present, due to the upward traction of the biceps on the upper fragment. On pronation and supination the rotation is not communi- cated to the head of the bone, and there is always to be found a local point of tenderness, generally with crepitus. In fractures of the shaft of the ulna localized tenderness may be the only symptom. The i"S2 of the x-rays is of great value in these cases, not only for diagnosis, but also in treatment, for accurate reduction in these cases is essential to insure a satisfactory functional result. Com plications. — In perhaps no fractures in the body are circulatory disturbances as frequent as in fractures of the forearm. They are generally due to faulty application of the splints and dressings, and result in local sloughs, ischemic paralysis of the muscles, and occasion- ally gangrene of the extremity. Delayed union and failure of union are to be feared if the reduction has been imperfect, and a temporary or permanent impairment of the function of pronation and supination FRACTURES OF BONES OF THE UPPER EXTREMITIES 843 frequently follows, not only from faulty reduction, but also from exuberant callus when the muscles, periosteum, and interosseous membrane have been extensively lacerated. In fractures of the radius alone, if there is any shortening, either from over-riding or from angula- tion, there will be a derangement at the inferior radio-ulnar joint with persistent pain and interference with pronation and supination, from a relative lowering of the ulnar head. Treatment. — When possible, fractures of the forearm should be examined, reduced, and the dressings applied under the guidance of the x-rays, so great is the importance of accurate coaptation of the fragments. When this is not practicable, reliance must be placed upon the correction of the apparent deformity and the restoration of function. When reduction has been effected, which often requires considerable force, the arm should be flexed at the elbow and the hand placed in a position midway between pronation and supination, with the thumb pointing upward. Retention in this position should be accomplished by the use of moulded plaster splints, or a circular plaster extending from the middle of the arm to the base of the fingers. If the circular plaster is used it should be completely cut through on both sides while still moist and then reinforced with a few turns of a gauze bandage. If there is the slightest sign of circulatory interference the latter must be removed and the two halves of the plaster bandage separated slightly. The use of a pad, graduated compress or rubber tubing between the bones to prevent lateral approximation, is of no value, and serves only to compress the tissues and favor interference with circulation. Inspection by the fiuoroscope or radiograph should always be made after the application of the final dressing. In fractures of the radius above the insertion of the pronator radii teres, if there is a marked tendency to supination of the upper fragment which is not corrected by flexing the elbow, it is desirable to dress the arm in a position of greater supination than normal. Extreme supina- tion is to be avoided, as it causes much discomfort to the patient. In the event of failure to reduce the deformity or to bring about accurate coaptation of the fragments, or if interposition of soft parts is suspected because of the lack of crepitus, open operation and accurate replacement are to be advised. Simple open reduction will usually be all that is necessary, but if the deformity tends to recur, suture or plating is indicated. Fractures in the Vicinity of the Wrist-joint. — These are fractures at the lower end of the radius (Colles' fracture), fractures of both bones just above the wrist, and fractures of the styloid process of the radius or ulna. Colles' Fracture. — -Colles' fracture, named after the Dublin surgeon who first accurately described the injury, consists in a fracture through the radius just above its inferior articular surface. The line of fracture usually occurs at the point where the shaft begins to widen into its 844 FRACTURES inferior extremity, as this is the weakest part of the bone, pwing to the fact that the hard, compact, outer covering is largely replaced by soft, friable, cancellous tissue before the bone expands into the bulky inferior extremity. In the majority of instances this fracture is caused by a fall on the outstretched hand, producing forcible overextension at the wrist. It is also often due to a "back fire" of the engine while the patient is cranking an automobile. This results, first, in a fracture at the weakest point, the general direction of which is usually transverse, the loose fragment being driven upward with the carpus, making with the upper fragment an angle the apex of which is directed toward the flexor surface of the arm. The most frequent displacements of the lower fragments are a radial or a dorsal shifting, a dorsal tilting or angulation, and an upward displacement or impaction. These may occur alone or in combination. The ulna maintains its relation to the upper fragment, and the lower fragment, together with the carpus, loses its normal relation to the ulnar head. With this is frequently associated rupture of the internal lateral ligament, or a fracture of the ulnar styloid. The resulting derangement of the inferior radio-ulnar joint is often overlooked and if uncorrected may give rise to permanent disability. Occasionally fracture at the lower end of the radius is produced by a fall or blow on the back of the hand, causing exaggerated flexion. This fracture, which has been carefully studied by J. B. Roberts of Philadelphia, presents a deformity which may be described as the opposite of that found in typical Colles' fracture, the lower fragment being driven downward and upward, causing with the upper an angle the apex of which points backward. Since the general adoption by surgeons of a>ray examinations in fractures, those occurring at the lower extremity of the radius have been found to present great variation in the line or lines of fractures and in the position of the fragments. The studies of Codman, of Boston, and of Beck, of New York, have demonstrated that the typical Colles' fracture, as described above, occurs only in about one-half of the cases, the other recognized forms being an oblique fracture through the base of the styloid process, an oblique fracture of the inner angle of the radius, epiphyseal separations, transverse and stellate fractures without displacement, and comminuted fractures. Fracture of the ulnar styloid is frequently present. Fracture of both bones above the wrist is uncommon. The fibres of the pronator quadratus are very apt to become interposed between the radial fragments and to interfere with accurate reduction. Diagnosis. — In a typical Colles' fracture with displacement, the deformity is strikingly characteristic (Figs. 401 and 402). There is radial shortening and radial shifting, giving the hand an inclination toward that side; the lower fragment and carpus project backward, while the upper fragment is pushed forward, giving an appearance which has been described as "the silver-fork deformity;" the lower extremity FRACTURES OF BONES OF THE UPPER EXTREMITIES 845 of the ulna is displaced inward and forward, which widens the wrist at that point. On palpation, the tip of the radial styloid will be found on a level with that of the ulna or a little above it, depending on the amount of impaction (normally it lies a quarter of an inch below); Fig. 401. — Deformity in extreme type of Colles' fracture. the angular deformity is easily appreciated; there is tenderness over the line of fracture and in the region of the ulnar styloid. If the fracture is not impacted, abnormal mobility and crepitus may be obtained. The ability to extend the hand is retained, while flexion is limited. The arm is usually pronated; supination causes pain. Fig. 402. — Deformity in extreme type of Colles' fracture. In Roberts' fracture by hyperflexion, the apex of the angular deformity points backward, and extension of the fingers and hand is limited and painful. In transverse fractures without displacement of the fragments no deformity may be present and local tenderness and impaired motion 846 FRACTURES may he the only symptoms. Fractures of both bones or of either styloid are easily recognized by localized pain, abnormal mobility, and crepitus. Complications. — Compound fractures in this region are exceedingly rare; when present, they are generally accompanied by extensive laceration of the soft parts with opening into the joint or synovial tendon sheaths, resulting, if infected, in permanent stiffness and loss of function. Extensive comminution or destruction of the cancellous bone tissue by impaction of the fragments may prevent complete reduction and result in permanent deformity. Ischemic wasting of the muscle from pressure of splints or bandages is common after this fracture and delays restoration of function. Chronic rheumatic arthritis frequently follows this injury in those predisposed to this affection. Prognosis. — While perfect restoration of function is to be expected when reduction has been complete, it should be remembered that this is often delayed, and stiffness of the carpal and phalangeal joints frequently remains for a long period, and requires persistent efforts on the part of the patient for its removal. A certain measure of deformity also results in the majority of instances, due to incomplete reduction of the angular defor- mity, to loss of substance from impaction, or to failure to re- store completely the displaced ulna. Fortunately, however, the persistence of deformity does not necessarily entail a loss of function, for a satisfactory res- toration of function generally follows, though perhaps tardily, even in cases of permanent and marked deformity. In uncomplicated cases bony union may be expected in four weeks. In aged and rheumatic subjects complete functional recovery is delayed, and often never realized. Treatment. — As this is one of the most frequent of fractures, and as the results of treatment are, in perhaps the majority of instances, imperfect, it is not surprising that such a large number of splints and devices for treating this injury should have been invented and Fig. 4»i:j. -Radiograph of case shown in Figs. 401 and 402. FRACTURES OF BONKS OF THE UPPER EXTREMITIES 847 advocated. The secret of success lies in early and complete reduction of the deformity, when this is possible, and not in the kind of retention apparatus used. When perfectly reduced there is little tendency to a reproduction of the deformity, and any simple dressing which protects against subsequent injury and keeps the parts at rest will meet the indications. The use of specially constructed splints to hold the hand in some abnormal and strained position, as the old-fashioned pistol splint, Fig. 404. — Author's dressing for Colics' fracture. (Radial view.) is to be condemned; they are of no value in preventing a recurrence of the displacement, and often produce permanent weakening of the wrist by stretching otherwise uninjured ligaments and tendons. In all save the simplest cases reduction should be effected under general anesthesia, either gas or ether, aided when possible by fluoro- scopic examinations. Reduction is accomplished best by grasping the injured hand as in the act of shaking hands. The hand is then drawn strongly toward the radial side to disengage the ulnar styloid, which is often caught in the torn lateral ligament. The hand is then slowly brought back to a hyperextended position to disengage the lower fragment, strong Fig. 405. — Author's dressing for Colles' fracture. (Ulnar view.) traction being made by the surgeon, while counter-traction is main- tained by an assistant holding the arm near the elbow. During this maneuvre the surgeon places the thumb over the carpal end of the lower fragment and two fingers under the lower end of the upper fragment, and by pressure backward and forward on these two points, and a similar motion of the hand, breaks up the impaction, if present, and pushes the lower fragment into place. If the lower fragment of the radius has been properly reduced the ulnar head will resume its 848 FRACTURES normal position, unless it has been forced through the anterior ligament. These maneuvres must be persisted in until the normal position has been restored, if possible, and if .r-ray examination shows imperfect reduction further attempts should be made. After reduction almost any splint that holds the forearm and wrist in slight flexion and mid- pronation will prevent recurrence of the deformity (Figs. 404 and 405). The use of a plaster-of-Paris palmar splint accurately moulded to the forearm and hand will do away with the necessity of pads and is a satisfactory dressing. When there are much comminution and considerable mobility of the fragments in restless children, and in alcoholic adults, with the possibility of delirium tremens developing, the use of a well-padded circular plaster bandage of the forearm and hand is to be advised. If the soft parts are severely contused, and if much edema follows the injury, after reducing the displacements, the arm should be treated for several days by rest on a pillow and wet dressings without the use of a retention apparatus. Fractures of the Carpal Bones. — While injury to the carpal bones is comparatively rare, it has been found to be of more frequent occur- rence than was supposed before the general use of the .r-rays. As the symptoms are often somewhat obscure, and as crepitus may be wanting, these injuries in the past were generally regarded and treated as bad sprains of the wrist. The classical paper of Codman and Chase, 1 however, has added much to our knowledge of the subject, and has given us a definite symptomatology of the more common forms of carpal injury. Fracture of the scaphoid is by far the most frequent; that of the other bones comparatively rare. This injury is not infrequently associated with dislocation forward of the semilunar, and in these cases the proximal fragment of the scaphoid is often carried forward with the displaced semilunar. In a few instances the proximal frag- ment has been forced backward through the dorsal carpal ligaments. Symptoms. — The symptoms of fracture of the scaphoid are the history of a trauma associated with forced hyperextension or, rarely, flexion of the wrist; the presence of pain and tenderness in the region of the tabatiere; swelling of the radial half of the carpal region; and painful limitation of extension and abduction of the wrist. The arrays may be necessary to establish the diagnosis, but it must be remem- bered in this connection that a bipartite variation in this bone has been demonstrated by Professor Dwight and others. Treatment. — In fracture of the scaphoid without displacement, the treatment should consist in immobilization of the parts for at least four weeks. If at the end of this period union has not taken place, there is little hope for subsequent repair. Massage and passive motion, however, in the majority of instances will bring about a good func- tional result. If pain and stiffness continue after a reasonable period 1 Annals of Surgery, March and June, 1905. FRACTURES OF BONES OF THE UPPER EXTREMITIES 849 Anteroposterior view. Lateral view. Figs. 406 and 407. — Carpal injury. Fracture of scaphoid and cuneiform with anterior displacement of ulnar fragment of scaphoid with semilunar and a portion of cuneiform. Fig. 408 Fig. 409 54 850 FRACTURES and are increased by normal use, or if the proximal fragment is dis- placed, it should be excised. Fractures of the other bones are rarely recognized except by the help of the z-rays. The same indications for treatment exist as in fracture of the scaphoid. Fractures of the Metacarpal Bones. — These fractures are not infre- quent. They are generally caused by direct violence, as a blow or fall on the back of the hand, or more commonly, from striking some Fig. 410. — Lateral view before reduction. Fig. 411. — Same after incomplete reduction. hard body with the closed fist. The latter, so-called punch fractures , are frequently encountered in boxers, and are said by Burrows to involve the base of the first and fifth metacarpals and the head or shaft of the others. Two or more of the metacarpal bones are often fractured by the same injury. Diagnosis. — The diagnosis is generally easily established by recog- nizing the presence of tenderness, crepitus, and false motion by pal- pation. If there is considerable swelling over the back of the hand, and if the fracture is near a joint, the signs may be obscured or wanting. FRACTURES OF BONES OF THE UPPER EXTREMITIES 851 Localized tenderness on direct pressure, and pain on striking the injured extremity of the bone while the fist is closed, together with localized pain on flexion and extension of the corresponding finger, render the diagnosis probable. Treatment. — The treatment of these fractures should consist in fixation of the wrist and hand, the fingers being flexed over a firm palmer pad. Fractures of the Phalanges. — As fractures of the phalanges are frequently due to direct violence, they are often compound. In simple fracture without displacement the diagnosis is not always clear, as it is often difficult to recognize or produce independent motion in short bones bounded above and below by very movable joints. Crepitus, how- ever, can generally be obtained by firmly grasping and fixing the neigh- boring joint or joints, and making strong lateral movements. Treatment. — In simple fractures without displacement or in which reduction has been effected, splints are rarely called for, the only treatment necessary being the appli- cation of a bulky dressing to avoid motion of the part. The employment in such cases of a bandage made of exceedingly thin gutta-percha tis- sue has been found the most satis- factory dressing. The small roller is first immersed in hot water, then applied to the fingers as an ordi- nary bandage, and when the part is covered by two or three thick- nesses of the tissue the hand is immersed in cold water, which hardens the gutta-percha, making a light and sufficiently firm cast. When the gutta-percha tissue is not available, two or three layers of ordinary zinc oxide adhesive plaster will answer the purpose. Where the displacement has been pro- nounced and where there is a tendency to recurrence, a light-moulded plaster splint applied to the palmar and lateral aspects of the mod- erately flexed finger will be found very comfortable and effective. In compound fractures which have become infected, amputation is f separation of the lower epiphysis have been reported. Fractures of the Fibula Alone. — Fractures of the fibula alone are exceedingly common if we include in this class Pott's fracture, in which the internal lateral ligament of the ankle or the tip of the internal malleolus is ruptured. The fibula may be broken in any part of its shaft by direct violence. When the injury is due to indirect violence, as by forcible inversion or eversion of the foot, the fracture always occurs in the lower third, from one to four inches above the malleolus. Displacement in these fractures is not marked, except in the case of Pott's fracture, in which the deformity is very characteristic. In this fracture, which is caused by violent eversion of the foot, alone or combined with external rotation, there is first a rupture of the internal lateral ligament or a fracture of the internal malleolus; this allows an outward dislocation at the ankle, which causes next a tearing apart of the tibiofibular attachment, and finally a fracture of the fibula just above the joint by forcible bending outward of the external malleolus. The fracture of the fibula is generally transverse, both fragments forming an angle the apex of which is directed inward against the tibia. If rotation played an important part in the injury, the fibular fracture may be oblique, extending well up the shaft. The force caus- ing this injury may cease at any point and occasionally the fibula is not broken, or it may be continued, causing a compound outward dislocation of the ankle. Very frequently there is associated with this a backward displacement of the foot at the tibiotarsal joint, which occasionally may be extreme. Diagnosis. — Both legs should first be inspected. Shortening, angu- lar deformity, and irregularity in outline suggest a fracture of both bones; eversion and prominence of the internal malleolus, Pott's fracture (Fig. 424); abduction or adduction of the knee, a fracture of the head of the tibia. The subcutaneous surface of the tibia should next be palpated from the knee to the ankle. This may reveal irregu- larities in outline and points of tenderness. The region of the fibula should then be palpated. This in the lower third is easy, but above that point more difficult, owing to the muscular coverings. Abnormal mobility may be sought for at the knee, ankle, or along the shaft- of the bones. Crepitus is often elicited by motion at the knee or ankle or by pressure on one or both bones in the neighborhood of any point of suspicious tenderness. While the presence of marked deformity, abnormal mobility, and crepitus will always serve to establish the diagnosis of fracture, frac- tures not infrequently occur without these signs. This is partieularly 868 FRACTURES true in fractures of the fibula near the ankle, where often the only signs are a limited point of tenderness and pain on motion. An exam- ination by the .r-rays is always of the greatest value, not only in determining the presence of fracture in these doubtful cases, but also to reveal the direction of the fracture, number of fragments, and character of displacement, especially in cases accompanied by considerable swelling. Prognosis. — In compound fractures of the leg, especially if the bones are comminuted and the soft parts extensively injured, the prognosis is exceedingly grave. Simple frac- tures, especially the oblique variety, not in- frequently become compound by carelessness in handling and in transportation. In simple fractures of one cr both bones the prognosis is generally favorable if reduction is perfect and can be maintained. Difficulty in per- manent fixation of the fragments in oblique fractures of the tibia is often encountered, and results in delayed union and shortening. Improperly treated Pott's fracture is almost sure to result in a weak ankle with eversion and flat-foot. Treatment. — Fractures of the upper ex- tremity of the tibia involving the joint should be reduced as soon as possible and enveloped in a plaster bandage from the upper thigh to the toes. This must be cut down on both sides in case the swelling should become excessive. If the x-rays show an incomplete approximation and proper technic can be observed, the fracture should be exposed and the fragments held together by screws, bolts, or plates. In transverse fractures of the shafts of the tibia and fibula, or of either bone alone, when there is little or no trauma of the soft parts, and when reduction can be effected, the immediate application of a plaster-of-Paris cast or the plaster posterior splint is to be recommended. In fractures by direct violence when there is extensive contusion of the soft parts with little or no displacement the leg may be placed in a fracture-box or sup- ported by side splints, and a wet dressing of aluminum acetate solu- tion applied until the swelling subsides, after which a plaster-of-Paris splint should be employed. Oblique fractures of the tibia with fracture of the fibula, when the tendency to overriding is marked, should be treated by the im- Fig. 424. — Pott's frac- ture: outward displacement. (Stimson.) FRACTURES OF BONES OF THE LOWER EXTREMITIES 869 mediate application of a plaster cast, when the condition of the soft parts will permit, full traction being maintained until the plaster hardens. In these fractures, which are often exceedingly difficult to reduce accurately, and which often become displaced during the application of the plaster cast, great help is afforded by the use of the rluoroscope during the application of the dressing. It not infre- quently happens that owing to the condition of the soft parts these oblique fractures cannot be treated by a plaster cast for several weeks after receipt of the injury. In these cases it is desirable to main- tain some degree of traction to prevent union with deformity. The Fig. 425. — Continuous traction in fracture of the leg. (Stimson.) short Desault splint will be found useful under these circumstances (Fig. 425). Open operation is indicated in shaft fractures when a proper reduction cannot be obtained by the closed method, or where the reduction cannot be maintained. This is especially true in oblique and spiral fractures. A curved incision is made over the antero- external aspect, and a flap lifted inward. After reduction a metal plate is applied to the outer side of the tibia. In the treatment of Potts fracture, early reduction under ether is of the greatest importance. If this can be accomplished before the excessive swelling, a far more accurate approximation can be accom- Fig. 426. — Dupuytren's splint. (Gross.) plished. In order to insure close union of the broken internal malleolus, or of the torn ligament, as well as complete reduction of the angular deformity in the broken fibula, the foot should be placed in a position of marked inversion. At the same time any posterior displacement of the astragalus must be overcome. The Dupuytren splint (Fig. 426) may be used as a temporary dressing until a properly fitting plaster splint can be applied. Vicious union following Pott's fracture results in marked deformity and functional disability. For this condition Stimson advises the following operation: Incision along the anterior border of the fibula, 870 FRACTURES through which the line of fracture is recognized and the fragments separated; second, incision along inner side of tibia, downward in front of inner malleolus as far as the tubercle of the scaphoid. The malleolar fragment, if united, is separated with a chisel and mallet, the joint opened, and the lower end of the tibia protruded, the astragalus liber- ated from adhesions and replaced, the incisions closed and the parts surrounded by a sterile dressing, and held in an overcorrected position by a plaster cast. "Where the pain and limitation of flexion are due to the posterior displacement of the tarsus, so that the anterior lip of the tibia impinges against the neck of the astragalus, great relief can be obtained by cutting away the projecting portion of the tibia. An additional ten degrees of flexion will often markedly improve the functional use of the foot. Compound fractures should be treated by free incisions, removal of blood clots, loose fragments of bone and torn muscle, thorough disinfection with hydrogen peroxide or tincture of iodine, after which the bones should be approximated and held, if necessary, by chromi- cized catgut sutures, and the wound partly closed with generous drainage. The employment of a plaster-of-Paris cast, with windows over the region of the wound and drainage openings, is of the greatest value in the treatment of these fractures, saving the patient much pain and discomfort during the earlier dressings. If no infection occurs, the primary dressings should be left in place for two or more weeks. At the end of this time, if the deformity is still sufficiently marked, and there is no active infection, it is often wise to expose the site of fracture, reduce the fragments, and hold them in place by a metal plate applied to the outer surface of the tibia. This should be removed after union is firm. In the presence of a progressive infection not controlled by local measures, amputation should be resorted to at an early period to save life. In cases of non-union persisting for six to eight months in spite of careful splinting, massage, and perhaps the injection of blood, the application of an inlay graft is indicated. Fractures of the Bones of the Foot. — Fractures of the bones of the foot are of fairly frequent occurrence, are often accompanied by wounds of the soft parts, and are generally due to direct violence. Fractures of the Calcaneum may be produced by a fall upon the feet from a height or by muscular action in falling upon the ball of the foot. In the first variety the fracture occurs generally in the middle cr anterior portion of the bone and is often comminuted. The simplest form is the impaction of the articular surface for the astragalus. In cases caused by muscular action the fracture is apt to be limited to the posterior portion of the bone, and often to the point of attachment of the Achilles tendon. Fractures of the Astragalus are caused by falls upon the feet, the bone being crushed between the tibia and calcaneum, or by forced flexion of the foot. In the former instance the fracture occurs in the FRACTURES OF BONES OF fHE LOWER EXTREMITIES 871 body of the bone and may be comminuted. In the latter the fracture is generally limited to the neck. Fractures of the Other Tarsal Bones are very rare. Those of the meta- tarsals and phalanges are more common, and, as in the case of the bones of the hand, are frequently compound. The diagnosis is often difficult and usually depends on .?-ray exami- nation. Fractures of the calcaneum can generally be recognized by local tenderness, mobility, and crepitus. If limited to the posterior portion of the bone, the fragment attached to the tendo-Achillis is generally drawn upward. Fractures of the astragalus may be assumed if there is localized pain on motion of the foot, crepitus, and inability to stand, and if fracture of the other neighboring bones can be excluded. In both the foot is flattened, the heel thickened, the malleoli nearer the ground, and the normal outlines obliterated. Fractures of the metatarsal bones and -phalanges can generally be recognized by pal- pation. In all of these fractures an z-ray examination is often neces- sary to arrive at a correct diagnosis; in fact, in all injuries about the ankle the x-rays should be employed as a routine practice. Regarding prognosis in fractures of the tarsal bones, it may be said that the result of treatment is generally unsatisfactory. Ely 1 has shown that a large percentage of the cases have more or less permanent disability. The causes of the disability are limitation of motion and persistent pain in walking. One of the most frequent sources of pain is the presence of a fragment of projecting bone or exostosis in the soft tissues of the heel ; another is the formation of a mass of callus beneath and about the tip of the external malleolus, to which attention has recently been called by Cabot and Binney. 2 Treatment. — In the treatment of fractures of the bones of the foot it is most important to restore the fragments to their normal positions and hold them securely until union has taken place, for it is only in this way that the normal arches can be maintained. In fractures of the posterior portion of the calcaneum, the knee should be flexed and ankle extended to allow the separated fragments to become approximated. In fractures of the body of the calcaneum and of the astragalus an effort should be made to break up any impac- tion which may be present and restore the normal outlines of the bone and shape of the ankle. This is often greatly facilitated by the use of the fluoroscope, which allows the surgeon constantly to compare the injured with the normal ankle. The best position for all fractures of the tarsal bones, with, the exception of those of the posterior portion of the calcaneum, is in strong dorsal flexion and inversion. Where the fragments cannot be satisfactorily readjusted by manipulation, open operation is to be advised. In fractures of the posterior portion of the calcaneum with marked separation of the fragments by upward traction of the Achilles tendon, uniting the fragments by chromic 1 Annals of Surgery, January, 1907. 2 Ibid. 872 FRACTURES suture or nails will insure practically a perfect result. In fractures of the body of the calcaneum with much comminution little can be done. Astragalectomy is often indicated for late disability. The removal of a projecting exostosis on the heel will often relieve a persistent pain in walking. Massage and passive movements are useful in recent cases, and should be regularly employed after the third week. The treatment of fracture of the metatarsal bones and phalanges should be by rest and moulded gutta-percha splints or a properly applied plaster bandage. In fracture of the first and fifth metatarsals where there is irreducible and marked displacement, open reduction is indicated. Wet dressings for the first few days after the injury are often necessary to subdue inflammation of the soft parts and joint membranes. CHAPTER XXX. DISLOCATIONS. The term dislocation in its surgical sense refers to a separation of the articular surfaces of two or more bones entering into the forma- tion of a joint. This separation is generally the result of injury, and such dis- locations are called traumatic dislocations; it is occasionally brought about by disease, resulting in the destruction of some or all of the tissues of the joint, after which the bone is displaced by muscular action; these dislocations are spoken of as pathologic or spontaneous dislocations: or it may be rarely the result of some prenatal defect or malformation, in which case it is characterized as a congenital dislocation. A dislocation is said to be complete when the articular surfaces are entirely separated from each other; incomplete, whey they remain at some point in contact. As in the case of fractures, dislocations may be simple or compound; the former when the lesion is covered by unbroken skin, the latter when the soft parts are lacerated, creating an external wound leading to the joint cavity. A complicated dislocation is one in which the trauma results in additional neighboring injury, as a fracture of one of the bones forming the joint, or injury to adjacent vessels or nerve trunks. The terms double, multiple, and symmetric are sometimes employed to describe dislocations when the injury results in more than one luxation. In the classification of dislocations the nomenclature follows no definite system. In some instances the name of the joint is used to describe the dislocation, as dislocation at the hip, shoulder, elbow; in other instances the distal bone is named, as dislocation of the head of the radius or a phalanx or metacarpal bone; in others the proximal bone is named, as dislocation of the acromial end of the clavicle or of the lower extremity of the ulna. In describing the direction of a dislocation, the terms anterior, posterior, external, and internal are employed at the knee, elbow, and a number of other joints; in other instances anatomic regions are used, as dorsal, pubic, sciatic, thyroid at the hip, subglenoid, subcoracoid, etc., at the shoulder. The term fracture-dislocation is used when both fracture and dis- location of one or more of the articulating bones have occurred. Causation. — The conditions which favor dislocations, and which, therefore, may be regarded as predisposing factors, are: the male 874 DISLOCATIONS sex, on account of greater exposure to injury; adult life, on account of the diminished liability to fracture; injury to certain joints, on account of their large range of motion and the absence of supporting ligaments, as the shoulder, which furnishes nearly one-half of all dislocations; or other joints, from their situation being more exposed to trauma, as the elbow- and finger-joints. Previous injury or disease may predispose a joint to dislocation by causing relaxation of the supporting capsule, ligaments, or muscles. The exciting causes of dislocation are direct or indirect violence and muscular action. As an example of direct injury causing dislocation, may be mentioned a fall upon the back from a height, giving rise to a dislocation of the spinal column ; indirect violence acts by a force received on one extrem- ity of a long bone being transmitted to a joint situated at a distance, as a fall on the hand or elbow causing a dislocation at the shoulder. The shoulder has been dislocated by violent muscular action alone, as in throwing a ball or stone. Muscular action, however, is more frequently a contributing cause, acting with direct or indirect violence. Pathologic Anatomy. — Under certain conditions of disease, as when a joint capsule has been greatly relaxed by distension w T ith fluid, or the normal support of muscular structures has been removed by paralysis, incomplete and even complete dislocation may occur without rupture of any of the periarticular soft tissues. Under normal conditions, however, when a dislocation occurs there is more or less laceration of the synovial membrane, capsule, ligaments, and adjacent muscular structures. In the ball-and-socket joints there is a rent in the capsule through which the head of the bone protrudes; in the hinge-joints the various ligaments are extensively damaged, and not infrequently the bony attachments of the ligaments are separated. Hemorrhage is always present from the torn tissues, and may be sufficient to form a distinct hematoma. Following the injury there is considerable inflammatory reaction, and in unreduced dislocations the resulting exudate becomes organized and is converted into dense connective tissue, which often renders subsequent efforts at reduction ineffectual. This formation of dense fibrous tissue will often surround the head of a dislocated bone, eventually forming a new socket, which may later become lined with a kind of synovial membrane allowing con- siderable motion. Diagnosis of Dislocations in General. — The symptoms commonly present in traumatic dislocation are pain, severe at the time of injury, continuing moderately while the luxation remains unreduced, but markedly increased by any motion of the part; deformity which is generally apparent on inspection; shortening or lengthening of the limb, according to the direction of the displacement, but without change in the length of the bone; alteration of the normal outlines of the joint; abnormal relation of the bony prominences; restricted motion of the limb; change in the axis of the displaced bone; absence of the head TREATMENT OF DISLOCATIONS IN CENERAL 875 of a bone from its socket, or its presence in an abnormal position; absence of a tendency to redisplacement after reduction. The differ- ential diagnosis between a dislocation and a fracture near a joint is often difficult. In general the symptoms which suggest dislocation are restricted motion, absence of crepitus, and the fact that the deform- ity is not reproduced after reduction. Those which suggest fracture are abnormal mobility, bony crepitus, and the tendency to recurrence of the deformity after reduction unless the parts are securely held. The symptoms common to both injuries are pain, deformity, oblitera- tion of the normal outlines of the joint, and a change in the axis of the bone. It should always be remembered that both fracture and dislocation may, and frequently do, exist in the same case. In spontaneous dis- locations there is a "history of previous paralysis or joint disease, and in congenital luxations the deformity is present from birth. In all doubtful cases the examination should be conducted under general anesthesia and controlled by a fluoroscopic examination or radiograph. Treatment. — Three methods are employed in the treatment of recent dislocations. These are reduction by manipulation, by exten- sion, and by open operation. Reduction by manipulation consists in executing certain movements of the limb by which the displaced extremity of the bone is made to reach its socket by the same route taken in its exit; the method is chiefly applicable to the shoulder and hip. The method by extension consists in the employment of traction on the limb, usually manual, with firm counter-extension by an assistant. The first effect of this is to relax the firmly contracted muscles, after which the bone often slips back into position or may be easily replaced by manipulation. Formerly, when more force was required than could be brought to bear on the part by manual trac- tion, compound pulleys were employed, but today open operation is generally preferred to the use of great force. Reduction by open operation should be resorted to when other methods fail. It should, however, never be undertaken unless the conditions are such as to insure a thoroughly aseptic operation. Under favorable conditions the joint can be freely exposed by incision, any bands of muscle or fascia preventing reduction divided or displaced, the bone replaced, the joint cavity thoroughly irrigated, the capsule and soft parts united, and an immovable dressing applied. The question of drainage should be settled by the operator at the time of operation, when the condition of the part is known and the perfection of technic appreciated. It is rarely necessary. In old dislocations the obstacles to reduction and restoration of function consist in firm fibrous adhesions holding the displaced bone in its abnormal position; filling up of the socket by fibrous material, which would prevent complete reduction; contractions of the attached muscles; and changes in the articular surfaces, as erosion or dis- appearance of the cartilage, which, if reduction could be accomplished, 876 DISLOCATIONS would prevent free motion in the joint. The question of attempting reduction in these cases should always be decided by the patient after a candid statement of the probabilities of improvement and the risks of operation. It should not be forgotten, moreover, that a fair functional result will often follow the formation of a false joint, and that late reduction is often followed by complete ankylosis from late changes in the bony surfaces. Attempts at reduction in these cases by manipulation and extension should not be undertaken after the formation of firm adhesions, as the danger of fracture is great, which, if it should occur, would neces- sarily diminish the chances of subsequent reduction by any means. The only safe method is by open arthrotomy, removal of the obstruct- ing fibrous material, loosening of the displaced extremity of the bone, and replacement by means of elevators or the McBurney hook. The subsequent steps of the operation are the same as in the case of recent dislocations. Gentle passive motion should be undertaken early; and later, massage, baths, and electricity will serve to restore the function of the surrounding muscles. Excision of the head of the bone, in cases of unreduced dislocation with greatly restricted motion, offers, espe- cially in the shoulder, a fair chance for an improved functional result. Compound dislocations of the larger joints are justly considered as among the most serious of bodily injuries. They generally outrank in gravity compound fractures, for the reason that a relatively greater degree of force is necessary for their production, and the resulting shock and laceration of neighboring tissues add greatly to their gravity. "When the injury to the vessels, nerves, and other soft parts is beyond repair, immediate amputation is to be advised; when there is a possibility of saving the limb, thorough disinfection of the wound, removal of torn or bruised fragments of muscle and fascia, reduction of the dislocation, with or without excision, partial closure of the wound with abundant drainage and an immovable dressing, and fixing the limb in a favorable position for ankylosis, are to be recom- mended. Later, evidences of infection call for prompt revision; and if progressive, amputation should not be delayed. Compound disloca- tions in the smaller joints present a less serious outlook, and con- servative measures may safely be carried out in the majority of instances. SPECIAL DISLOCATIONS. Dislocation of the Jaw. — Dislocation of the jaw is of fairly frequent occurrence, and is caused by opening the mouth widely, as in laughing, vomiting, or in dental procedures; occasionally it is produced by a blow on the chin while the jaws are separated. It is generally bilateral, although it may occur on one side only. When the mouth is opened, the condyles of the jaw normally pass forward to the articular emin- ences; a sudden increase in this movement, with strong contraction of the external pterygoid muscles, results in the condyles slipping over SPECIAL DISLOCATIONS OF THE JAW 877 this eminence into the temporal fossa. The interarticular fibrocarti- lage is generally drawn forward with the condyle. A mild form of recurring partial dislocation or subluxation is occasionally seen. It is usually unilateral. After yawning or opening the mouth wide the jaw will fail to completely close, and there will be a dull pain at the site of the affected joint. It is due to faulty adjustment of the meniscus to the movements of the condyle. Diagnosis. — In bilateral dislocation the mouth is widely open, the lower jaw projecting somewhat forward (Fig. 427), the coronoid process can be felt through the mouth to be displaced forward under the zygoma, and a hollow can be seen in front of the ear. Speech and swallowing are impaired, and salivation is present. If the dis- location has occurred on one side only, there is less deformity and the chin is deviated toward the normal side. Fig. 427. — Bilateral dislocation of the lower jaw. (Hamilton.) Treatment. — Reduction is generally easy. The surgeon should place his thumbs, protected with towelling or gauze, upon the last molar tooth of each side, and make firm pressure downward until the muscles are relaxed; he should then press the jaw backward and at the same time elevate the symphysis by the disengaged fingers. After reduction it is well to apply a four-tailed bandage to prevent, for a few days, any excessive movements of the jaw until the torn capsule has united. Unilateral subluxation generally can be reduced by direct inward pressure over the affected condyle. To prevent its recurrence the 878 DISLOCATIONS patient should school himself never to open his mouth beyond a safe distance. Dislocations of the Clavicle. — Dislocations of the clavicle may occur at either end. Dislocations at the sternal end may be forward, back- ward, or upward; dislocations at the acromial end may be upward or downward. Of these, the dislocation forward of the sternal extremity, and upward of the acromial extremity, are the commonest. All other varieties are rare. Dislocations of the Sternal End. — These are produced generally by some force applied to the tip of the shoulder forcing it violently back- ward, forward, or downward, which drives the sternal extremity of the bone from its bed. Direct violence by blows or crushes may give rise to the backward variety. Diagnosis. — In all cases there is a history of injury, Avith pain in the region of the sternoclavicular joint and inability to use the arm. In forward dislocation the head of the bone rests in front of the sternum, forming a distinct prominence at the root of the neck; the shoulder is apparently nearer the median line than normal; the sternomastoid muscle is rigid. In backward dislocation there is a depression at the point normally occupied by the head of the bone; the neck is rigid; the shoulder falls inward. There may be congestion of the arm, dyspnea, or dysphagia from pressure on the venous trunks, trachea, or esophagus. In the upward variety the dislocated end of the bone can be distinctly felt above the sternum, behind the sternal origin of the sternomastoid muscle. Treatment. — In all these varieties reduction is generally easy, and is effected by placing the knee firmly against the spine between the scapulae and with both hands drawing the shoulders backward. Direct pressure over the head of the displaced bone will often facilitate reduction. The classic retention dressing is a figure-of-eight bandage applied posteriorly to the shoulders. Stimson advises holding the shoulder forward by an anterior figure-of-eight or Velpeau bandage. If the tendency to displacement is marked, and especially if in backward dislocations pressure symptoms are unrelieved, open opera- tion with suture or excision of the head of the bone is indicated. Dislocations of the Acromial End. — Upward dislocations are generally produced by applications of force to the tip of the shoulder in a down- ward direction plus vigorous contraction of the trapezius muscle which draws the acromial extremity of the bone upward. If the displacement is at all marked it means that the coracoclavicular ligament has been ruptured. The increased distance between the clavicle and the cora- coid, as seen in the away, will demonstrate this. In the rare downward displacements the force is usually applied from above in a downward direction to the upper surface of the clavicle. The outer extremity of the bone is displaced downward,and slightly backward, the acromion often overriding it. Subcoracoid downward dislocations of the acromial DISLOCATIONS OF THE SPINE 879 extremity of the clavicle have been described, although their existence is doubtful. Diagnosis. — In the common upward luxation the pain at the time of the injury may be slight, and the resulting disability insignificant, but in most instances voluntary motion and pressure over the dis- placed bone are accompanied by severe pain, and there is inability to raise the arm above the head. The shoulder-tip is depressed, the acromial extremity of the clavicle projects upward and may override the acromion, and, unless the swelling is marked, its smooth articular facet can be easily recognized by palpation. In the downward variety, in addition to the localized pain, there may be numbness of the arm from pressure on the brachial plexus. The deformity is easily recognized by inspection or pal- pation. The clavicle is depressed, the acromion is prominent, and its articular facet may often be palpated. Treatment. — Reduction in the upward variety is easily accomplished in most cases by carrying the shoulder upward and backward, with pressure over the displaced extremity of the bone. In this variety, retention of the bone in its normal position is often difficult, but is best effected by the use of Moore's figure-of-eight bandage from the elbow to the opposite shoulder, or by Stimson's method, which consists in placing the centre of a long strip of adhesive plaster under the flexed elbow, and carrying the ends upward, one in front and one behind the arm, and crossing them just over the acromioclavicular joint. Dur- ing its application the elbow should be pushed forcibly upward and the clavicle downward (Fig. 428). In the downward variety, after reduction the arm should be fixed to the side by a sling and chest-binder. If the coracoclavicular ligament has been ruptured it should be exposed and repaired. Dislocations of the Spine. — If one examines the spinal column in an articulated skeleton, it will be found that in the cervical region the articular processes look generally upward and downward, and that the slight anteroposterior slope is not sufficient to prevent a separation and sliding forward of the upper vertebra upon the lower if sufficient force is applied. It will also be seen that an acute anterior flexion of the Fig. 428. — Stimson dressing for an acromioclavicular dislocation. 880 DISLOCATIONS head and neck would tend to separate these articular processes and produce such a sliding forward. In the dorsal and lumbar regions, how- ever, the direction of the articulating surfaces is such that this dis- placement could not occur without a fracture of the articular processes unless the upper vertebra was drawn vertically upward for a con- siderable distance, a condition which would practically never result from any ordinary violence. These conditions will serve to explain the fact that dislocations of the spine alone without fracture are exceedingly rare, and are practically limited to the cervical region. The association of dislocation with fracture is of frequent occurrence, however; these injuries, which are spoken of as fracture-dislocations, have been described in the section devoted to Fractures of the Spine. Dislocations of the vertebra?, like fractures, are generally produced by some force which bends the spine beyond its normal limits of motion. This bending may be the result of direct violence, as a blow on the back of the neck, or by the indirect violence of a force applied to a distant point of the vertebral column, as diving into shallow water and striking the head violently against the bottom, causing sud- den acute flexion. Muscular action may also play a part in the pro- duction of dislocation, as in a sudden violent rotary motion of the head during anteroposterior or lateral flexion. Several varieties of dislocation occur in the cervical region. In the great majority of instances the upper vertebra is displaced forward on the underlying one. If the articular processes on both sides are separated, the dislocation is spoken of as a bilateral dislocation; if on one side only, a unilateral dislocation. The former is almost always produced by a violent bending forward of the head and neck; the latter by extreme lateral flexion alone or combined with rotation. Dislocations backward, unilateral and bilateral, have been recorded, but are very rare. Bilateral dislocation in opposite directions — that is, a displacement of the articular process forward on one side and back- ward on the other — has also been recorded. In forward bilateral dis- locations the ligaments are torn, the intervertebral disk is lacerated, the articular processes of the upper vertebra lie in the intervertebral notches of the lower, the cord is crushed, the surrounding plexus of veins is injured, giving rise to hemorrhage into the canal, and the nerves are stretched or crushed as they emerge from the intervertebral fora- mina. In unilateral dislocation the deformity is less, and the cord may be simply stretched and not crushed ; the same is ,true in the bilateral variety if the dislocation is not complete, as occasionally happens. In these cases the articular surfaces are not entirely sepa- rated from each other. Diagnosis. — As in fractures of the cervical spine, there is a history of a severe injury resulting in exaggerated flexion of the vertebral column, followed generally by complete paraplegia below the point of injury. There is localized pain in the neck, which is increased by any motion of the head. Neuralgic pains and muscular twitchings DISLOCATIONS OF THE SPINE 881 are occasionally observed over the distribution of one or more of the spinal nerves emerging from the injured intervertebral foramina. Hyperpyrexia, inequality of the pupils, and localized vascular disturbances, occur in certain cases, due to sympathetic irritation. In unilateral or incomplete dislocation the cord injury may be slight, and the resulting symptoms irregular and due simply to trac- tion on the cord and its nerves, or to pressure from bone or hemor- rhage. In these cases the motor paralysis is generally more extensive than the sensory; both may be incomplete. In addition to the symptoms enumerated above, examination will reveal the presence of deformity and rigidity of the neck, with an absence of crepitus. There is irregularity in the line of the transverse and spinous processes. A prominence of the dislocated vertebral body may often be seen or felt at the back of the pharynx ; the respira- tion is embarrassed if the injury is above the origin of the phrenics. Priapism is present in some cases. Cystitis and bed-sores are prone to develop soon after the injury, and eventually give rise to septic- symptoms. Prognosis. — This depends entirely upon the amount of injury to the cord. If there is evidence of a complete transverse crushing lesion, death is certain within a few days, if the injury is above the exit of the phrenic nerve; at a later period, if below this point. In incomplete dislocations, when the injury to the cord is slight or the symptoms due to pressure or hemorrhage, recovery may occur. Treatment. — In unilateral or incomplete dislocations, and in all other cases in which there is no evidence of a complete transverse lesion of the cord, an attempt at reduction should be made. If the cord is crushed, reduction will accomplish nothing, as restoration of function is impossible. On account of a possible error in estimating the degree of injury to the cord, some surgeons advise that an attempt at reduc- tion be made in every instance. The methods employed to effect reduction in cervical dislocations are of two kinds: by manipulation, and by open operation. The method by manipulation consists in the employment of vertical extension, flexion, and rotation. In a case under the observa- tion of the writer, a dislocation high up in the cervical region was readily reduced by simply placing one hand under the patient's chin, the other under the occiput, and exerting steady traction upward, the patient being in the sitting position. The replacement was accom- panied by a distinct snap, such as is often observed in the replacement of other dislocated bones. In forward dislocations the surgeon should first employ flexion to disengage the articular processes, then traction upward and extension of the head. In unilateral dislocations lateral flexion toward the healthy side should precede upward traction and rotation. Counter-extension is often necessary in carrying out these manipulations, and is favored by placing the patient on an inclined plane. If reduction is not accomplished by these means, the patient 56 882 DISLOCATIONS should be prepared for operation, which is carried out in the following manner: Under general anesthesia the patient should be placed face downward on an operating-table, the head projecting slightly over the end and firmly held by an assistant, who later will thus be able to execute such movements as are directed by the surgeon. An incision six inches in length is then made in the median line over the spinous process, the edges of the wound are firmly held apart by retractors, and all muscular and aponeurotic structures dissected free from the spines, laminae, and transverse processes. As soon as this is accomplished and the bleeding arrested, the glistening articular facet of the inferior vertebra can generally be seen, with the displaced articu- lar process of the dislocated vertebra above. The assistant in charge of the head, under the direction of the surgeon, executes the various movements of flexion, upward traction, rotation, etc., necessary to disengage the locked articular processes, after which the surgeon by the use of hooks and elevators can generally succeed in prying or drawing the bone back into place. The wound should then be closed with a small drain, an antiseptic dressing applied, and the head and neck firmly held by a plaster-of-Paris bandage. It should be remembered that efforts at reduction have occasion- ally caused sudden death when the injury was located high in the cervical region. As dislocation unaccompanied by fracture practically never occurs below the cervical region, the reader is referred to the section devoted to Fractures of the Spine for a consideration of these injuries in the dorsal and lumbar regions. Dislocations of the Sternum. — Bony union of the three portions of the sternum occurs late in life if at all, rarely before the fortieth year. Before ossification takes place separations may occur at the lines of union, giving rise to two varieties of dislocation: those of the body from the manubrium, and those of the ensiform. Dislocations of the Body from the Manubrium are generally produced by some violent crushing force, and are often accompanied by other injuries. The symptoms are localized pain, which is increased by respiratory efforts, and the presence of an elevation of the upper border of the gladiolus, which can be easily palpated under the skin. This trans- verse ridge lies at the point of junction of the second costal cartilages; and as these generally remain attached to the manubrium, there is on either extremity of this ridge a small depression caused by separation of the cartilages. The treatment is the same as in fractures of the sternum. Reduction is accomplished by direct pressure aided by dorsal flexion of the trunk, after which the movements of the chest should be limited by a tight binder. Dislocations of the Ensiform are exceedingly rare, and are produced by direct violence or tight lacing. The base of the ensiform may be DISLOCATIONS OF THE SHOULDER 883 displaced backward, or its tip may be directed inward, toward the spine, at right angles to the body of the sternum. The symptoms are pain, which is increased by motion or taking food. In several reported cases persistent vomiting was the most prominent symptom. Treatment. — Reduction is best accomplished by incision and re- placement of the bone, with suture, if necessary, to prevent recur- rence. Dislocations of the Ribs. — A few examples of dislocation of the head of the ribs from the vertebral column have been reported, generally accompanied by fractures of the spine or other severe injuries. Separa- tion of the ribs from their costal cartilages, or of the costal cartilages from the sternum, or from each other, has also been occasionally observed. As these* injuries are similar in their etiology, symptoma- tology, and treatment to fracture of the ribs, the reader is referred to the Chapter on Fractures for their diagnosis and management. Dislocations of the Shoulder. — Dislocations of the shoulder are the most frequent of all dislocations, in fact statistics show that they occur more often than all other dislocations combined. The causes of this frequency are, in their order of importance: the large range of motion in the joint, the frequent strain of injury, and the shallowness of the glenoid cavity. Causes. — Dislocations of the shoulder are caused both by direct and indirect violence. Direct violence may cause dislocation by a fall on the point of the shoulder, but more commonly by a blow on the upper part of the arm while it is abducted or raised above the head, the direction of the blow being such as to drive the head of the bone away from the glenoid cavity. Indirect violence causes dislocation generally by a fall on the hand or elbow. Muscular action not infre- quently acts as a contributing cause, as evidenced by the frequency of dislocations occurring during athletic sports, especially wrestling. Shoulder dislocation is essentially an injury of middle adult life, the same cause producing fracture of the clavicle or dislocation of the elbow in early life, and not infrequently fracture of the neck of the humerus in later life. Varieties. — The following are the varieties of shoulder dislocation, in the order of their frequency: subcoracoid, subglenoid, subspinous, subclavicular, and supracoracoid. In the subcoracoid variety (Fig. 429), which is by far the most com- mon, the capsule is ruptured anteriorly, allowing the head of the bone to protrude through the rent. The head rests under the coracoid process generally above the tendon of the subscapularis, although the fibres of this muscle may be ruptured or pushed forward, embrac- ing the head of the bone. If the articular surface of the humerus is in contact with the margin of the glenoid, this dislocation is often spoken of as incomplete; if the head is pushed partly beyond the coracoid, the term intracoracoid dislocation has been suggested; if 884 DISLOCATIONS completely beyond the coracoid, the dislocation should be classed as subclavicular. In the subglenoid variety the lower portion of the capsule is ruptured ; the head of the humerus rests below the glenoid fossa, on or in front of the axillary border of the scapula, below the tendon of the subscapularis. In extreme downward displacement of the head of the bone the arm may remain erect, the elbow being usually flexed and the forearm resting behind the head; this rare form is described as the Ju.ratio Fig. 429. — Subcoracoid dislocation at shoulder. Notice change of axis of humerus, flattening of shoulder and prominence under coracoid. erecta. Certain authorities believe that most dislocations are primarily subglenoid, the injury being received while the arm is raised above the head, and that the head of the bone originally lying beneath the glenoid fossa subsequently assumes a position under the coracoid by lowering the arm or other active and passive movements. In the subspinous variety the head of the bone passes through a rent in the posterior portion of the capsule, and rests below the spine of the scapula between the infraspinatus and teres minor muscles, covered bv the deltoid. DISLOCATIONS OF THE SHOULDER 885 The supracoracoid variety is extremely rare, and is usually accom- panied by fracture of the coracoid or acromion; the head of the bone is displaced upward and rests upon the coraco-acromial ligament. Symptoms and Diagnosis. — The symptoms of a dislocation of the shoulder are pain and inability to use the limb. The signs are, on inspection, deformity due to flattening of the shoulder, prominence of the acromion, alteration in the axis of the arm, a swelling in the region of the displaced head of the bone; on palpation, absence of the head of the bone from the glenoid fossa, presence of the head of the bone in some abnormal position, muscular rigidity causing diminished motion of the joint, absence of crepitus, and inability to bring the elbow in contact with the chest when the hand is placed on the opposite shoulder; on mensuration the limb is found to be lengthened in the subglenoid, and shortened in all other dislocations. An x-ray examina- tion is always desirable, not only to show the exact position of the head but demonstrate the presence or absence of associated fracture, which may or may not be suspected. Complications. — Aside from the contusions often present from the original trauma, complicating injuries are comparatively rare. Press- ure on the nerve trunks or the larger vessels may give rise to numbness and circulatory disturbances in the arm; injury to these structures occasions paralysis and hematomata. Of the nerves, the circumflex is the one most frequently affected, and the symptoms, if at all pro- longed, are probably due to a neuritis from the trauma of the original injury, or more often to the attempts at reduction. Of the vessels, the circumflex and subscapular are the ones generally torn, and wounds of the axillary artery and vein have been reported. Laceration of the muscles attached to the greater and lesser tuber- osities, or fractures at the points of their attachment, may occur, and by their retraction produce a permanent weakening of the joint, a tendency to habitual dislocation, or an obstacle to reduction by their interposition between the articular surfaces. Fractures of the anatomic or surgical neck of the humerus occasionally occur as a complication of dislocation at the shoulder, and present serious difficulties in treat- ment. Fractures of the acromion, coracoid, and glenoid are also occasionally present, the former generally associated with supracoracoid dislocation. Treatment. — Two methods are in general use: reduction by extension or traction, and reduction by manipulation. The former is the older; the latter, the modern method. Reduction by Extension. — The usual method is to place the patient on a table and make counter-extension by a sheet carried around the thorax and firmly held by an assistant. The surgeon then grasps the affected arm near the wrist and applies traction outward at a right angle with the body. Steady traction for a few seconds will generally cause the contracting muscles to relax, after which the head of the bone usually slips into place. Another method, formerly 886 DISLOCATIONS extensively employed, is that of the "heel in the axilla." The patient lies upon his back on the floor or on a bed; the surgeon sits facing the patient on his injured side, and after removing his shoe places the heel in the axilla, grasping the wrist of the patient with his hands or by means of a clove-hitch; steady traction is made downward, using the heel as a lever to force the head of the bone toward the glenoid cavity. The method is often successful, but is inferior to that of outward traction, and is said to be responsible for a number of injuries to the vessels and nerves. The method suggested by Stimson is often successful. The patient lies upon the affected side on a stretcher with his arm projecting through an opening in the canvas body and hanging down in full abduction. A two- to five-pound weight is attached to his forearm by adhesive plaster. He is allowed to remain in this position for even half an hour if necessary. The weight will gradually tire out the muscles, and the displaced head then easily slips back into place. When this method is employed, gentle swinging of the hand may aid the head in re-entering the capsule. In the rarer forms of dislocation the direction of the traction may with advantage be altered to meet the requirements of the case, such as traction upward in the luxatio erecta and downward in the supra- coracoid dislocation. Method by Manipulation (Kocher). — place the patient on a chair or stool, flex the elbow, and, keeping the arm close to the side of the thorax, rotate the humerus outward until the flexed forearm is parallel with the transverse plane of the body; then, holding the forearm in this position, carry the elbow slowly upward along the anterior surface of the chest until it reaches a point opposite the ensiform; quickly rotate the forearm inward until the hand touches the opposite shoulder and lower the elbow. The head of the bone may slip into place during any of these motions (Figs. 430, 431, and 432). This method is chiefly applicable to the subcoracoid variety, and if uncomplicated, reduction is easily accomplished in the majority of instances. It may fail, however, if the displacement is markedly inward and downward, or if the capsule is extensively lacerated. Under these conditions extension is to be preferred. While reduction of dislocations at the shoulder may usually be accomplished without general anesthesia, it is frequently desirable to employ it, not only to relieve the pain necessarily incident to the manipulation, but also to overcome muscular spasm. The employment of forcible reduction by means of compound pulleys, especially in old dislocations, as suggested and practised by the older surgeons, is not to be recommended. If a recent disloca- tion cannot be reduced by the expenditure of a moderate degree of force, it is because some mechanical obstruction exists which is best removed by open operation. If the dislocation is complicated by a fracture of the neck of the DISLOCATIONS OF THE SHOULDER 887 Fig. 430. — Kocher's method of reduction of dislocation of shoulder: first position. Fig. 431. — Kocher's method: second position. sss DISLOCATIONS humerus, it should be treated by open operation, reduction of the upper fragment being accomplished after the parts are thoroughly exposed, by means of the McBurney hook (Fig. 433), or by the use Kocher's method: third position. of elevators and other prying instruments. In old injuries of this kind excision of the head of the bone is often necessary. In the reduction of old dislocations of the shoulder, one should remember that the resulting motion is often less than that obtained Fig. 433. -McBurney's hook for making traction upon the dislocated upper fragment. (Stimson.) by allowing the head of the bone to remain in its abnormal position, where a false joint generally forms and a fair amount of motion develops. Moreover, such attempts in the presence of dense adhesions DISLOCATIONS OF THE ELBOW 889 not infrequently result in fracture, or injury to important vessels and nerves. If such an attempt is to be made, ether should be given, and the adhesions gradually broken up by various motions of the shoulder until the bone is freely movable, after which reduction may be attempted by manipulation or extension. If the adhesions are not readily broken up by a moderate amount of force, or if there is some evident mechanical impediment to reduction, an open operation is to be advised and the procedures carried out under guidance of the eye. After reduction has been accomplished the arm should be kept moderately quiet for two or three weeks until the wound in the capsule unites. This is accomplished best by the sling and body-binder at first, and later the sling only may be used. Passive motion in uncomplicated cases should be begun after the second or third day, and at the end of a*week in operative cases. Complete restoration of function is to be expected in recent uncom- plicated cases. Regarding the amount of motion to be obtained after reduction of old or complicated dislocations, the prognosis should be guarded. Much may be accomplished by persistent efforts at passive or active motion, by massage, heat and electricity. Dislocations of the Elbow. — Dislocations of the elbow are of fre- quent occurrence, especially in children. As has been pointed out, they are generally produced by a fall on the hand, the arm being extended, an injury which in adult life is likely to cause dislocation of the shoulder, or occasionally a fracture of the surgical neck of the humerus. Both bones may be dislocated backward, forward, inward, or outward; the radius alone may be displaced backward, forward, or outward; the ulna backward, forward, or inward. The classification is extended still further by the use of the terms complete and incomplete in connection with any of these varieties, and by describing a given injury as a combination of two forms, as a dislocation backward and outward. Backward dislocation of both bones is very common; all other forms are comparatively rare. In backward displacements of both bones the injury is almost always produced by a fall upon the extended hand. The ability which most children possess to slightly hyperextend the arm may be partly responsible for the frequency of this dislocation in early life. Both bones of the forearm are displaced backward, the coracoid process of the ulna resting in the olecranon fossa, the head of the radius behind the external condyle. If the coracoid process still rests upon the trochlea, the dislocation may be termed incomplete. With this injury there is always considerable laceration of the ligaments; the coracoid process or the radial head may be broken or the brachialis anticus muscle torn from its attachment. In forward dislocations, which are extremely rare, the injury is produced by a fall or blow on the point of the elbow while the forearm is acutely flexed, or a blow upon the flexor aspect of the arm while 890 DISLOCATIONS the elbow is flexed and the hand grasping some firm object. ( lonsider- ablymore force is required to produce this injury, and the accompany- ing laceration of the tissues is greater in extent. The olecranon may lie wholly in front of the condyle-, or it> tip may rest upon the articular surface. In lateral dislocations, of which the inward is somewhat more com- mon, luxation is seldom complete. In the external variety the sigmoid cavity of the ulna re>t> upon the capitellum, the radial head lies exter- nal to the condyle. In the internal variety the sigmoid cavity lie- in contact with the extra-articular portion of the internal condyle, and the head of the radius is generally in front of the articular surface and somewhat below it. In mired dislocations, backward and outward, or backward and inward, the primary injury is probably the backward one, the lateral displacement occurring secondarily to it. Fig. 434. — Backward dislocation of radius and ulna. lAshhurst.) Dislocations of the ulna alone are extremely rare, the backward displacement being the one most frequently reported. Dislocations of the head of the radius are comparatively common, and are often accompanied by fracture of the shaft of the ulna. The forward displacement is commonest; next in frequency comes the backward; the outward is very rare. Diagnosis. — In all dislocations of the elbow there is a history of injury followed by localized pain and inability to use the joint. In backward dislocations of both bones the arm is semiflexed and stipul- ated, the forearm appears shortened when viewed from in front, the humerus appears shortened if viewed from behind; there is a distinct prominence of the olecranon, the normal relations between it and the epicondyles is lost, the articular surface of the humerus may be felt DISLOCATIONS OF THE ELBOW 891 in front of tlu* joint below the natural crease in the skin, and the head of the radius may be palpated behind the external condyle (Fig. 434). In the rare forward displacement the arm is in partial flexion; the olecranon no longer forms a prominent point on the posterior aspect of the joint, the forearm is lengthened, and the displaced bones may be readily felt in front of the joint. In lateral dislocations the diagnosis is usually made without difficulty, for in the complete outward luxation the deformity is so great that it could hardly be mistaken for any other condition, and in partial lateral displacements the signs are generally sufficiently characteristic to enable one to arrive at a correct diagnosis in the absence of great swelling or other complicating injury. Thus in the external variety the rounded head of the radius can be felt moving with rotation of the forearm to the outer side of the condyle; while in the internal' variety the olecranon and sigmoid cavity of the ulna can be readily appreciated, lying to the inner side of the internal condyle. In each variety there is a prominence above on the opposite side of the joint, formed by the overhanging condyle and articular surface of the humerus. Dislocation of the ulna alone may be recog- nized by the altered relations of the olecranon and condyles, by the presence of the radial head in its normal position, and by palpating the olecranon and sigmoid cavity in an abnormal locality. Dislocation of the head of the radius is recognized by the history of injury, pain in the joint, the inability to flex the arm beyond a right angle or to supinate without pain. In the anterior variety the arm is partly flexed and in a position midway between pronation and supination; the head of the bone can be felt in front of the joint just above the external condyle. In the posterior variety there is an outward inclina- tion of the arm, and the head of the radius may be felt posteriorly . In external displacement the joint is widened, the arm inclined out- ward, and the head of the bone easily palpated to the outer side and above the condyle. Subluxation of the head of the radius occurs frequently in young children, and almost always from lifting the child by one hand. The symptoms are sudden pain and inability to use the arm. The anatomic relations of the joint appear normal; there is tenderness over the head of the radius with inability to supinate without pain. Other motions are free but very painful. Complications. — Dislocations of the elbow are rarely compound. Fractures of the coracoid process and olecranon are fairly common complications of backward dislocation. Fracture of the shaft of the ulna is a frequent complication of dislocation of the head of the radius. The occurrence of fracture of the head of the radius and external or internal condyle of the humerus has also been observed. Injury of the brachial artery or of the median or ulnar nerve occasionally occurs. Treatment. — The method usually employed in the reduction of backward dislocations at the elbow is the following: The patient 892 DISLOCATIONS is seated in a chair. The surgeon places his foot upon the chair and his knee in the bend of the elbow. By grasping the wrist and forcibly flexing the arm over the knee reduction is usually accomplished. Stimson points out that this method, although generally successful, is faulty in that it stretches or lacerates structures not ordinarily injured by the original trauma. He recommends steady traction, the arm being extended until the coracoid process is drawn well below the olecranon fossa, then forward pressure on the displaced bones with gradual flexion. If the coracoid process is not readily disengaged by simple traction, slight pronation, hyperextension, or direct pressure backward on the upper part of the forearm will serve to lift it out of the olecranon fossa. In dislocations of the head of the radius when associated with fracture of the ulnar shaft, extension followed by flexion and direct pressure on the head of the bone will occasionally serve to effect reduction. The radial head is either pulled down through the orbicular ligament or the latter is torn vertically. In the former case reduction cannot be accomplished, and in the latter the ligament will probably not resume its normal position. For this reason it is wiser to cut down and expose the head and the anterior portion of the joint. If the ligament is torn its ends can be pulled around the radial neck and sutured in position. If the ligament is still intact and dorsal to the radial head it may be cut and the two ends made to pass around in front of the bone, where they can be sutured in normal position. In old unreduced cases it may be necessary or wiser to remove the head and neck of the radius. In the other rare forms of displacement, extension followed by flexion and direct pressure on the displaced bones is the method to be recommended. In all dislocations, especially if difficulty is experienced in reduction, general anesthesia should be used. The after-treatment should consist in fixation of the joint by an angular splint or sling and body bandage until the torn structures are healed. Passive motion should be employed after the swelling and pain have subsided. If in backward dislocations the coracoid process is fractured, the arm should be held in a position of flexion to a degree somewhat more than a right angle, and passive motion should be delayed until union has taken place. Old dislocations occasionally may be reduced by first breaking up the adhesions by forced flexion and extension, and then applying strong traction and the various methods employed in recent cases. The writer saw a backward dislocation reduced in this manner seven months after the injury. In the majority of instances, however, it is safer to perform an open operation and replace the bones under guidance of the eye. Dislocations of the Wrist. — Inferior Radio-ulnar Articulation. — The inferior radio-ulnar articulation is not infrequently separated in Colles' fracture and in injuries about the wrist. In these cases the inferior DISLOCATIONS OF THE WRIST 893 extremity of the ulna is displaced outward and downward, as evidenced by the increased distance between the two styloid processes. Forward or backward dislocations of the inferior extremity of the ulna unasso- ciated with Colles' fracture are rare, and are generally caused by forcible pronation or supination. In these cases the distance between the two styloid processes is diminished, and the projecting extremity of the ulna is readily recognized above or below the radius and often over- riding it. Reduction is generally effected by traction and pressure over the displaced bone, aided, if necessary, by pronation and supination. In old unreduced cases the function of the wrist can be almost entirely restored by a subperiosteal resection of the ulnar head and neck. Dislocations at the Radiocarpal Articulation. — Dislocations at the radiocarpal articulation are rare, and are caused generally by falls upon the palm or back of the hand, the former producing a dislocation backward of the carpus, the latter a dislocation forward. In the backward dislocation the deformity resembles that produced by a Colles' fracture. It is to be distinguished from the fracture, however, by the fact that the normal relations exist between the two styloid processes; that the joint is not widened; that the smooth surface of the projecting carpal bones may be felt lying above the radius; and by the absence of crepitus and ease of reduction. In the forward dislocation the radius and ulna form a prominence on the back of the wrist, while the displaced carpus projects in front. These dislocations are easily reduced by traction and direct pressure, after which a splint should be worn for a week or ten days. Dislocations at the mediocarpal articulation have been reported, but are exceedingly rare. The separation takes place between the first and second rows of the carpus. The hand with the second row of carpal bones may be displaced both backward and forward. Reduction is generally easy. Dislocations of the individual bones of the carpus are occasionally observed. Of these, the semilunar is the one most frequently dis- placed, and the dislocation is generally forward. It is not infrequently associated with fracture of the scaphoid. In these cases the proximal fragment of the scaphoid may be displaced forward with the semilunar bone. The others are rarely displaced alone. These injuries are generally produced by forced flexion or extension at the wrist; they are occasionally compound, and reduction is often difficult or impossible. The diagnosis may be established by observing the relations of the displaced bone to the radius, ulna, metacarpal bones or tendons, by the shape of the projecting mass, or by an .r-ray examination. In the semilunar dislocations, the displaced bone can be felt on the flexor aspect of the wrist, pushing forward the median nerve and the flexor tendons of the fingers which are thereby rendered tense, produc- ing flexion of the digits. The pain from median pressure may be very extreme and be the most marked symptom. In the treatment 894 DISLOCATIONS of semilunar dislocations, the hand should be hyperextended, then gradually flexed, pressure being made upon the displaced bone. In recent cases this maneuvre often succeeds. Reduction of the other bones sometimes can be effected by traction and pressure combined with forcible flexion and extension. Carpal dislocations frequently are irreducible. When the semilunar and proximal fragment of a fractured scaphoid are displaced forward, reduction is usually impos- sible except by open operation. Even with the bones exposed as they lie in the carpal canal, it often is impossible to get them back through the rent in the anterior carpal ligament without too much trauma. In such cases removal of the two fragments will give a very useful and painless wrist, though the motion will be restricted. When the dislocation is compound it is always wiser to remove the bone. Dislocations at the carpometacarpal articulations are exceedingly rare. The first metacarpal bone is the one most frequently displaced, and the direction of the displacement is usually backward, caused by some force applied to the thenar eminence. The thumb is shortened and flexed; the proximal extremity of the metacarpal bone rests upon the trapezium, forming a prominence between the extensor tendons of the thumb. The trapezium may be felt on the palmar surface. Dislocation of most of the other individual metacarpal bones has been recorded, as well as two or more together. In a few instances the four inner bones have been displaced forward or backward, and one or two examples of luxation of all five have been reported. Dislocations of the Bones of the Hand. — Dislocations at the meta- carpophalangeal joints are more common injuries than the preceding, and are generally single. The thumb is the one most frequently involved; next in frequency comes the index finger. The others are rare. The anterior or glenoid ligament of this articulation is a firm car- tilaginous plate, which is attached firmly to the base of the palmar surface of the phalanx. Laterally it blends with the capsule and receives some of the fibres of the lateral ligament. Its proximal extremity is but loosely attached to the metacarpal shaft, below the head, by a thin lax fold of synovial membrane. In extension this plate moves over the head of the metacarpal. It frequently has developed in its substance a sesamoid bone. In the thumb it receives on either side a large portion of the fibres of insertion of the short thumb muscles. When the phalanx slips back over the meta- carpal head to a full right angle it passes beyond a dead centre and becomes locked. This constitutes a complete dislocation. If the phalanx be flexed without being pulled down over the metacarpal head the latter will be forced through or above the proximal edge of the anterior ligament and the latter be interposed between the two bones. The phalanx now is in the same axis as the metacarpal but in a posterior plane. This constitutes a complex dislocation. The only difference between a complex dislocation in the thumb and the other DISLOCATIONS OF THE HAM) S<.!.-> fingers is that the short muscles attached to this cartilaginous plate, by their contractions, tend to hold the latter more firmly in place behind the metacarpal head. Dislocation of i he first phalanx of the thumb backward on the meta- carpal bone is an injury which has received a great deal of attention from surgeons on account of the difficulty in the reduction of the com- plex variety. It is far more frequent than the similar condition in the other fingers. In order to reduce a complete dislocation at the metacarpophalan- geal joint the phalanx and metacarpal are grasped firmly and the Before reduction. After reduction. Figs. 435 and 436. — Complex dislocation of metacarpophalangeal articulation of thumb. former pulled downward and away from the latter, at the same time great care must be exercised to maintain extension until the anterior ligament can be made to clear the metacarpal head. Then the phalanx is sharply flexed into its normal position. Unless this is observed there is great danger of converting it into the complex form. In a complex dislocation the phalanx must be first extended to a right angle to tighten the anterior ligament. It may then be possible by strong traction backward and downward to disengage the glenoid ligament from its position behind the metacarpal head. If this fails it is necessary to make a lateral incision near the palmer aspect and 896 DISLOCATIONS pull this ligament forward with blunt hook or elevator. In the thumb it may be necessary to split the ligament in a longitudinal plane. Forward dislocations at this articulation are rarer and more easily treated. They are generally caused by forcible overflexion. The phalanx lies in front of the metacarpal bone, which is seen to project posteriorly. Reduction is accomplished by traction, flexion, and direct pressure. Difficulty may occasionally be encountered in firmly grasping a finger in order to exert sufficiently vigorous traction. In these cases the Levis splint may be employed (Fig. 437). Dislocations at the first and second phalangeal joints are compara- tively common, and result from injuries received in baseball and other athletic sports, as well as from blows and falls. The diagnosis presents no difficulties unless the parts are extensively bruised and swollen. Reduction is accomplished by traction and direct pressure. Dislocations of the Hip. — The hip is a large ball-and-socket joint of great solidity. It is rarely dislocated. The reason of its unusual strength lies in the fact that although the range of its motion is large, its socket is deep, its ligaments tough, and its surrounding muscles Fig. 437. — Levis' extension apparatus. heavy and firm. Another element which serves to prevent the head of the bone from leaving its socket is atmospheric pressure. The acetabular cavity is almost hemispherical, and the head of the femur fits its hollow so accurately that air cannot enter until its complete removal, which requires a very considerable amount of force. The weakest part of the acetabular rim is below, owing to the thinness of the bone and the presence here of the cotyloid notch. The capsular ligament, which is attached to the pelvis at the circumference of the acetabulum, and to the femur at or near the junction of the neck with the shaft, is thickened at several- points, forming the iliofemoral, pubo- femoral, and ischiofemoral ligaments. Of these, the most important is the iliofemoral, or Y-ligament of Bigelow, which passes from the anterior inferior spinous process, downward on the capsule, as a thick band of dense fibrous tissue, dividing at about the middle of the anterior surface of the capsule into two bands, one passing to the greater and one to the lesser trochanter (Fig. 438). This ligament is said by Bige- low to be capable of sustaining a strain of from 250 to 750 pounds. The weakest part of the capsule is at its inferior and posterior por- tion. When the thigh is flexed, abducted, and rotated inward, the posterior inferior portion of the capsule is rendered tense, and if any DISLOCATIONS OF THE HIP 897 force is then applied to the body or limb to increase this strain upon the ligament it may rupture and the head of the bone be forced out of its socket. Thus one of the most frequent causes of dislocation at the hip is a blow from some heavy falling object received on the back of a person in a stooping position. It is probable that in most dis- locations the head of the bone leaves the socket at this point, and its ultimate location will depend largely upon the direction of motion in the affected limb immediately after the receipt of the injury. Thus if the limb, after the head of the bone leaves the socket, is abducted and rotated outward, the head will follow the rim of the acetabulum in an inward direction and lodge in the thyroid foramen or on the pubis; whereas if the leg is ad- ducted and rotated inward, the head of the bone will pass to the outer side of the acetabular rim and lodge in the sciatic notch or on the dorsum of the ilium. Ex- aggerated secondary motion of the limb in either direction may carry the head of the bone to a point immediately above the acetabulum. That the head of the bone takes one of these directions and lodges generally at or near a point which gives to the luxation the name iliac, sciatic, thyroid, or pubic, is due largely to the integrity of the ilio- femoral ligament. If the trauma is of sufficient severity to rupture this band, the dislocation may be- come compound, or the head of the bone be driven to some un- usual position, constituting one of the irregular forms occasionally encountered. Dislocation of the hip is essentially an injury of early or middle adult life. It is most frequently observed in indi- viduals between fifteen and thirty years of age, although cases have been reported as occurring at any age between six months and ninety-one years. It is far more frequent in men than in women, the proportion being about 8 to 1. Classification. — In spite of the many elaborate classifications which have been suggested for dislocations of the hip, the profession gen- erally still employs the old terms iliac, sciatic, thyroid, and pubic, to describe the common varieties. In the writer's opinion, it is far more important to recognize the method of production of these dif- 57 Fig. 438.- The iliofemoral, or Y-ligament. (Bigelow.) 898 DISLOCATIONS ferent varieties and the probable course taken by the head of the bone in reaching its abnormal location, than to seek to establish a more scientific classification. Four regular dislocations, the iliac, the sciatic, the thyroid, and the pubic, will therefore be described, and three irregular forms, the supracotyloid, the infracotyloid, and the perineal. Diagnosis. — In all cases there is a history of some severe injury fol- lowed by pain about the joint and inability to use the limb. Deform- ity is always present, its character depending upon the variety of the dislocation. There is greatly diminished mobility at the joint, and all movements of the limb cause accentuation of the pain. True bony crepitus is absent, but a sensation suggesting crepitus is often imparted to the hand by moving the limb, caused by the rubbing of the head of the bone against, the torn muscles and ligaments. In addition to these, each variety has its own characteristic signs, which will be enumerated separately. Iliac Dislocation. — The head of the bone in this variety rests upon the dorsum of the ilium above the tendon of the obturator interims muscle. When the patient rests in the dorsal position, the thigh will be seen to be partly flexed, adducted, and inverted; the long axis of the femur, if continued, would cross the opposite thigh at the junction of the middle with the lower third (Fig. 439). Flexion and adduction are tolerated but painful; extension and abduction impos- sible. The knee is slightly flexed, and the ball of the great toe rests often on the dorsum of the opposite foot. There is considerable short- ening, the greater trochanter lies above Nelaton's line, the fascia lata is relaxed, and the head of the bone may often be felt in its abnormal position. If the capsule is extensively lacerated and the outer portion of the Y-hgament torn, the head of the bone may lie immediately above the acetabulum and the limb assume a position of marked eversion. This, however, is extremely rare. Sciatic Dislocation. — In this variety the head of the bone lies on the ischium near the sciatic notch, below the tendon of the obturator interims. The symptoms in general resemble the iliac dislocation, but are less marked. There are slight shortening, slight flexion, slight inversion and adduction; the axis of the affected thigh, if extended, would pass through the opposite knee. If both thighs are brought to a right angle with the body, the patient being in the recumbent position, the shortening of the affected thigh is materially increased. Thyroid Dislocation. — The limb is lengthened, abducted, and slightly everted. The trochanter is below Nelaton's line. There is slight flexion at the hip from tension of the psoas and iliacus. In the recumbent position the limb cannot be fully extended, and the knees cannot be approximated without severe pain. There is spasm of the adductor muscles (Fig. 440). Pubic Dislocation. — The limb is shortened, abducted, and mark- edly everted. The head of the bone can generally be felt internal to the anterior inferior spinous process, resting on the horizontal ramus DISLOCATIONS OF THE HIP VI! I of the pubes; or, rarely, above it (suprapubic variety). The hip is flattened ; the prominence normally formed by the greater trochanter is absent; adduction and internal rotation are exceedinglv painful (Fig. 441). Of the rare irregular dislocations, the supracotyloid resembles somewhat the dorsal with eversion, or the pubic, but it differs from them in that it is caused by some severe injury which forces the head of the bone directly upward through a rent in the strong anterior portion of the capsule. There is shortening, with marked eversion Fig. 439. — Iliac disloca- tion. (Tillmanns.) Fig. 440.— Thyroid disloca- tion. (Tillmanns.) Fig. 441. — Pubic dislo- cation. (Tillmanns.) and abduction. The head of the bone may easily be palpated just below the anterior superior spinous process. In infracotyloid dislocation there are lengthening and generally marked flexion, with either slight inversion or eversion of the foot. The head of the bone is directly below the acetabulum and rests on the ischium. It is probably the primary stage of many dislocations which are subsequently converted into one or another of the four regular forms. The perineal variety is exceedingly rare. In it there is extreme 900 DISLOCATIONS abduction with flexion. The head of the bone rests in the tissues of the perineum, where it occasionally presses upon the urethra, causing retention of urine. Complications. — Compound dislocations of the hip are exceedingly rare. Fractures of the pelvis or of the neck or shaft of the femur are occasionally encountered, the latter produced sometimes by attempts at reduction. Laceration of the femoral vessels has been reported; also injury to the sciatic nerve. Simultaneous dislocation of both hips has been recorded in a few instances. Prognosis. — In recent cases reduction generally can be accomplished and a good functional joint expected. In old cases efforts at reduc- tion are attended with considerable risk, chiefly of fracture of the neck or shaft of the femur. The functional result in old, unreduced dislocations is occasionally fair, especially in the thyroid variety, as Nature will sometimes form a new and comparatively strong joint, allowing a considerable amount of mobility. In the other varieties much disability results from the shortening, limited motion, and lack of parallelism of the limbs. Treatment. — In hip dislocation, perhaps more than in any other, the rule should be observed of causing the dislocated head of the bone to follow backward its path to the socket. The methods of manipu- lation popularized by Bigelow, and now generally practised by the profession, have wholly replaced the older and unscientific procedures, formerly practised, of forcible traction by pulleys, etc. Bigelow's methods are carried out in the following manner: The patient should be thoroughly anesthetized and placed on his back on the floor; the pelvis should be steadied by an assistant. The sur- geon grasps the ankle of the affected limb with one hand and the knee with the other. The leg is then flexed to a right angle with the thigh, and the thigh to a right angle with the body. In the pos- terior displacements the thigh is then further flexed, adducted, and rotated inward; the knee is then circumducted externally, and while this is being done direct sudden upward traction is made, after which the leg is extended and brought to the floor. In the anterior dis- placements the thigh is flexed and abducted, then circumducted internally, with upward traction and rotation, and finally fully extended. In the rare dorsal dislocations with eversion, the displace- ment should first be converted into a regular dorsal dislocation with inversion by flexion and inward rotation, then replaced by the method just described for dorsal dislocations, or simply by upward traction in the flexed position. In irregular dislocations with extensive laceration of the capsule, direct traction upward with the thigh flexed at a right angle with the body, and direct pressure toward the acetabulum on the displaced head of the bone, will usually succeed. Dislocations of the Patella. — The patella may be dislocated outward, inward, and by rotation on its longitudinal axis. DISLOCATIONS OF THE KNEE 901 In the outward variety, which is the commonest, the patella lies to the outer side of the external condyle. If unaccompanied by rotation, its inner edge only is in contact with the condyle. Generally, however, a certain degree of external or internal rotation is present, which allows either its anterior or posterior surface to come into contact with the condyle. It is caused by direct violence, as a blow on the inner edge of the bone, or by muscular action, especially in a condition of genu valgum. In the rare inward dislocations the bone lies to the inner side of the joint, beyond the articular surface of the internal condyle, in contact with the condyle only by its external border; or if rotation exists, by its anterior or posterior surface. This variety also is usually the result of direct violence. In the dislocations' by rotation of the patella on its longitudinal axis three degrees are recognized: first, partial rotation with lateral dis- placement, when the outer or inner edge of the patella lies in the intercondyloid notch, the bone resting on the external or internal condyle, the so-called incomplete external or internal dislocation; second, when the rotation is through a larger arc, so that one edge of the patella rests in the intercondyloid notch and the other points vertically upward, the so-called edgewise dislocation; and third, when complete rotation has taken place, the anterior surface of the patella resting upon the articular surface of the femur, and the articular surface of the patella lying immediately underneath the skin. All of these rotary displacements are caused by direct violence applied to the outer or inner edge of the bone, generally during moderate flexion of the knee. Diagnosis. — This is generally easy. In the lateral displacements the joint appears widened, with an irregular projection on the side of the displacement. The normal prominence of the patella is absent and a depression exists between the condyles. The bone may easily be recognized by palpation in its abnormal position. There are pain and immobility of the joint. In rotary displacements the position of the bone may be readily made out by inspection and palpation. Treatment. — In all of these dislocations the thigh should be flexed on the body and the knee fully extended to relax the quadriceps exten- sor muscle. When this is accomplished, reduction may easily be effected by pressure on the displaced bone. After reduction the joint should be immobilized for a week or more, and later treated by massage and hot and cold douches if synovitis exists. Any tendency to redisplace- ment should be combated by a knee-cap or elastic bandage. Dislocations of the Knee. — Dislocations of the knee are rare, and are generally the result of severe injury. They are frequently com- pound, and often are accompanied by grave complications. They are classified according to the direction taken by the displaced tibia, and in the order of frequency are forward, backward, outward, inward, and by rotation. 902 DISLOCATIONS Forward dislocation is by far the commonest. It may be complete or incomplete, and is frequently compound. It is caused generally by some severe force resulting in hyperextension of the leg, or by direct violence applied just above and in front of the knee or below and behind. When complete, the popliteal surface at the back of the tibial head rests upon the anterior surface of the condyles of the femur. The overriding of the bones may amount to several inches. The ligaments of the joint are extensively torn; the popliteal vessels and nerves are tightly stretched over the condyles of the femur and may lie in the intercondyloid notch. More or less injury to these structures generally results, especially to the artery, which may be torn or later may become occluded by rupture of its internal and middle coats. The vein is less frequently injured. When compound, the opening is usually behind, allowing the condyles of the femur to protrude. In backward dislocations, when complete, the anterior border of the articular surface of the tibia rests upon the posterior surface of the condyles of the femur. It is caused by direct violence above or below the knee, or by a strong forward motion of the body while the leg is fixed. In this dislocation the ligaments are not, as a rule, so extensively lacerated as in the forward displacements. The patella may be fractured or displaced laterally, or the quadriceps tendon may be torn. The popliteal vessels and nerves are stretched and often injured, as in the forward variety. In incomplete forward or back- ward dislocations the articular surfaces are not entirely separated, and there is no overriding. Lateral dislocations are less frequent, and may be complete or incomplete. The complete outward or inward luxations are exceedingly rare; the articular surfaces are entirely separated; the head of the tibia lies to the outer or inner side of the femur, producing great deformity. A certain amount of anteroposterior displacement may exist with rotation. The patella and its tendon, if not injured, lie obliquely. In incomplete lateral displacements, which are far more common, the outer tuberosity of the tibia rests upon the inner condyle, or the inner tuberosity upon the outer condyle; there is less deformity, and the injury to surrounding structures is less extensive. In rotary dislocations the leg is violently rotated around its longi- tudinal axis, the ligamentous structures are torn, and one or both condyles are displaced forward or backward. Diagnosis.— The recognition of these dislocations is generally easy, as the bones are so superficial that any change in their relations is readily appreciated by inspection and palpation. In the complete forms the deformity is great, there is considerable shortening, and the flat articular surface of the tibia is easily felt in its abnormal position. In the complete forward variety the leg is extended, the antero- posterior diameter of the joint is greatly increased, the skin above DISLOCATION OF THE SEMILUNAR CARTILAGES 903 the patella is relaxed and presents one or more transverse folds, the flattened articular surface of the tibia may be felt in front, and the rounded condyles of the femur behind; the leg is numb and cold from pressure on the popliteal nerves and vessels. The pulse in the posterior tibial and dorsalis pedis vessels may be absent. In complete backward displacement the leg is hyperextended, the con- dyles of the femur are in front and the head of the tibia behind; pressure symptoms on the nerves and vessels are the same. In com- plete lateral displacement the deformity is so characteristic as to leave no doubt regarding the nature of the injury. In incomplete luxation and rotary displacement there is no shortening, and, as a rule, no pressure symptoms. The outlines of the bones, however, can be readily made out, and in the absence of swelling the diagnosis is without difficulty. Prognosis. — In complete dislocation of the knee the prognosis is grave from the fact that from 20 to 25 per cent, of the cases are compound, and also from the fact that in a large proportion of the forward or backward displacements the popliteal vessels are so injured that gangrene of the leg results. In other instances neuritis develops, and causes grave sensory, motor, and trophic disturbances. In the incomplete varieties the prognosis is more favorable, but more or less impairment of function in the knee-joint is to be expected. Treatment. — In all varieties of this injury reduction is easily accom- plished under general anesthesia by simple traction and direct pressure over the displaced bone. The presence or absence of pulsation in the arteries of the foot should be noted before and after reduction. Occa- sionally in thrombosis of the popliteal artery from rupture of its inner coats collateral circulation will be established, and the early treatment therefore should be expectant. If signs of gangrene appear, amputa- tion is indicated. When the circulation is unaffected and reduction is accomplished, the leg should be immobilized for several weeks to allow repair to take place in the torn ligaments; and if considerable inflammatory reaction follows, the use of an ice-bag is to be recom- mended. If the displacement has been sufficient to rupture the crucial ligaments, the joint should be opened in order to suture these structures. For this purpose the longitudinal incision, splitting the patella, gives the best exposure. This should only be done after at least five days have elapsed since the accident and where perfect technic can be observed. Passive motion should be undertaken after the second week and a knee-cap worn for several months. In compound dislocations the joint should be freely opened, irri- gated, and drained. If acute general sepsis follows, early amputation will be necessary to save life. Dislocation of the Semilunar Cartilages. — The semilunar cartilages of the knee-joint are occasionally displaced inward or outward by some slight injury or unusual motion of the articulation. The inner meniscus is the one oftenest affected, and the displacement is gener- 904 DISLOCATIONS ally accompanied by a bruising or a partial or complete rupture, from its being caught and squeezed between the condyle of the femur and articular surface of the tibia. The cause of the displacement is gener- ally a twisting or rotary motion of the body while the feet are on the ground and the knee partly flexed with the weight on the opposite leg, so that the muscles of the injured side are relaxed. It frequently occurs in athletes, especially those who play foot-ball, tennis, or golf. The symptoms of this affection are generally characteristic, and resemble those caused by the presence of a floating cartilage in the joint. They were described in the early part of the nineteenth century by Hey, who called the condition an "internal derangement of the knee." It is only within the past twenty years that the true pathology of the affection has been recognized. Diagnosis. — As a result of some sudden twisting motion of the leg, the patient immediately experiences a severe lancinating pain in the knee, with "locking" of the joint. The pain is often so severe that the patient falls to the ground and is unable to execute any voluntary movement of the limb. The symptoms may persist for some time and gradually disappear, or as a result" of forcibly flexing and extend- ing the leg all pain may suddenly be relieved and the functions of the joint completely restored. There is, however, a strong tendency to recurrence, and patients are often more or less disabled by these frequently recurring attacks. Not infrequently a certain amount of effusion appears in the joint after such an attack, requiring rest in bed and the application of an ice-bag. Examination of the joint may be negative, or, in the rare outward displacements of the meniscus a projection may be felt between the articular surfaces of the tibia and femur. Treatment. — For the acute attack prompt flexion and extension of the leg will often give immediate relief. The pain of this maneuvre however, is often severe and an anesthetic is frequently desirable. If tenderness and an effusion into the joint follow the attack, the patient should be kept in bed, the joint immobilized, and an ice- bag applied for several days. To prevent recurrences the patient should avoid weight-bearing until the fluid has disappeared from the joint and the muscles of the thigh have regained their tone suffi- ciently to hold the knee in a stable condition. The laxity of the muscles is a strong predisposing factor in the recurrence of the locking. The use of a steel brace has been recommended, which prevents rotation and allows only a limited amount of flexion and extension at the knee. Not infrequently, after a large number of such attacks complete relief will follow the giving up of athletics in general or the particular sport which seemed to occasion the symptoms. In many cases, however, the attacks continue in spite of the greatest care, and in these open operation is to be recommended. The operation is best performed with the knee flexed, the leg hanging DISLOCATIONS OF THE ANKLE 905 over the edge of the operating table. An incision is made along the inner border of the patella to a point opposite the joint line, then curved backward for about two inches. The capsule is divided and the joint cavity opened. By retracting the patella and its ligament outward, the articular surface of the tibia is well exposed and the internal meniscus easily examined. If found to be displaced but uninjured, it may be sutured in place. If ruptured, or completely dislocated inward so that it lies in the intercondyloid space, it should be removed by severing its anterior and posterior attachments. The joint cavity is then irrigated with normal salt solution to remove any blood clots, and the wound closed with a running suture of catgut for the capsule, and two or three interrupted silkworm-gut sutures for the skin. After applying a sterile gauze dressing the limb is extended and placed in a long posterior, splint. As soon as the wound is healed, passive motion and massage should be employed. Dislocations of the Fibula. — The upper extremity of the fibula may be dislocated backward, forward, or upward. These displacements may be caused by direct violence, indirect violence, by an injury to the ankle and upward pressure on the fibula, and by violent contrac- tion of the biceps muscle, the latter producing generally the backward luxation. The lower extremity of the fibula has been displaced backward with- out fracture in a few recorded cases. All of these varieties are rare, and are easily recognized. They are generally reduced by direct pressure, aided by flexion of the knee to relax the biceps, in those at the upper end; and by e version or inversion of the foot in those occurring at the inferior extremity. Dislocations of the Ankle. — Dislocations of the ankle are fairly fre- quent, and a large number of varieties have been described. The separation may take place at the tibiotarsal articulation, where the foot with the astragalus may be displaced backward, forward, out- ward, inward, or upward; at the astragalocalcaneoid and astragalo- scaphoid joints, the subastragaloid dislocation, when the direction of displacement of the foot may be backward, forward, outward or inward; at both of these joints, resulting in a displacement of the astragalus alone, which may be forward, backward, inward, outward, or its position simply changed by rotation. Tibiotarsal Dislocations. — These are generally produced by falls upon the foot in the position of dorsal or plantar flexion, or by strong abduction or adduction of the foot, the former resulting in antero- posterior displacements, the latter in lateral luxations. In the antero- posterior displacements the foot with the astragalus may be displaced backward or forward. The backward dislocation is the commonest. Symptoms. — In backward dislocations the foot is shortened, the heel is prominent, and the tendo Achillis tense; the malleoli project anteriorly and their relations with the tarsus are altered. In forward 906 DISLOCATIONS dislocations the foot is lengthened, the heel and tendo Aehillis are less prominent, and the space on either side of the tendon is occupied by displaced tibia and fibula. The malleoli are nearer the heel and lower than normal; the articular surface of the astragalus can be felt in front of the tibia. Incomplete backward or forward dislocations may occur, the symptoms of which are the same but less marked. The lateral dislocations are almost always accompanied by fracture. In the outward variety the accompanying fracture is of the fibula, and has already been described as Pott's fracture. In this the dis- location is incomplete, and consists in rotation outward of the tarsus without displacement of the astragalus beyond the malleolus. In the incomplete inward variety the inner malleolus or lower part of the tibia is fractured; the rotation of the tarsus is inward. Complete dislocations outward or inward when the astragalus is displaced wholly without the tibiofibular mortice are exceedingly rare. In these the limb is shortened, the ankle is greatly increased in breadth, and the foot is in extreme outward or inward rotation. Upward dislocation is exceedingly rare. It is caused by a fall from a height on the feet. The inferior tibiofibular articulation is separated and the astragalus is driven upward between these bones. The joint is widened ; the malleoli approach the sole of the foot. It is generally accompanied by fracture. Treatment. — In all of these dislocations reduction is easily accom- plished. In anteroposterior displacements the knee should be flexed to relax the tendo Aehillis. The foot should then be grasped by the surgeon and firm traction made while the knee is held by an assistant. This, with pressure forward or backward on the lower extremity of the leg and a slight rocking motion of the foot, will generally succeed. In lateral displacements the reduction of the fracture as well as the dislocation must be made, and in the outward variety the foot should be held in an inverted position by a Dupuytren splint or plaster-of- Paris cast. In dislocations without fracture the joint should be immobilized for ten days, after which massage and passive motion should be employed. Subastragaloid Dislocations. — In these luxations the astragalus remains with the tibia and fibula. The separation takes place between the astragalus and the scaphoid and os calcis. The displacement of the foot is generally obliquely backward and inward or backward and outward. Dislocations directly backward, or forward, or laterally, are extremely rare. These injuries are caused generally by severe twists of the ankle. They are not infrequently accompanied by frac- tures of the malleoli. Diagnosis. — The diagnosis is not always easy in the presence of extensive swelling. In backward and inward displacements the dor- sum of the foot appears shortened, the heel is lengthened, there are inversion of the foot and a prominence externally and in front, caused DISLOCATIONS OF TARSAL BQNES 90' by the displaced astragalus and external malleolus. In backward and outward displacements the foot is everted and the astragalus and internal malleolus form a prominence internally and in front. The relation between the head of the astragalus and the malleoli is normal. There is preservation of the anteroposterior movements in the tibio- tarsal joint, but the lateral and rotary movements of the ankle are lost or painful. Treatment. — Reduction is not always easy, owing in certain cases to engagement of the head of the astragalus under the tendon of the tibialis anticus muscle in the backward and outward variety, and occasionally to fracture of the astragalus in the others. Reduction should be attempted in all cases by flexing the knee to relax the tendo Achillis, and by downward and forward traction on the foot, with direct pressure backward, on the lower extremity of the tibia. Dislocations of the Astragalus. — The astragalus may be forced from its bed and displaced in almost any direction. The cause is generally a fall upon the foot from a height, or any severe twisting injury to the ankle. The most frequent direction of the displacement is forward and outward or forward and inward; occasionally the bone is rotated without being forced out of its bed. In the forward and outward variety the foot is inverted, and the bone can easily be felt lying in front of the tibia, resting upon the outer tarsal bones. In the forward and inward variety the foot is everted and the bone can be seen and felt just in front of the internal malleolus. In the rotary displacements little or no deformity may be present, but motion is much restricted and painful. Treatment. — The treatment should consist, first, in attempting reduction under anesthesia by traction and direct pressure over the bone, the knee being held in a flexed position by an assistant, who also exercises strong counter-extension. If this fails, open incision and replacement or excision of the bone should be practised. Mediotarsal Dislocations. — In this dislocation, which is exceedingly rare, the cuboid and scaphoid are separated from the astragalus and os calcis. The displacement is generally downward. In the complete dislocation the foot is shortened, the arch obliterated by the depressed cuboid and scaphoid, and there is a prominence on the dorsum made by the head of the astragalus and the cuboid surface of the os calcis. This dislocation may be accompanied by fracture of one of the bones or of the external malleolus. Dislocations of the Other Bones of the Tarsus. — These may occur separately or in various combinations. Those of the cuneiform bones are commonest, and of these the first is more often displaced singly than the others. Dislocation of the metatarsal bones may occur singly or in combina- tion. The entire metatarsus has been displaced from the tarsus in a number of cases. These luxations are generally upward, but may occur downward, and in case of the entire metatarsus, laterally. The 908 DISLOCATIONS first metatarsal bone is most frequently dislocated singly, and the direction of the displacement is generally upward on the dorsum. Dislocations of the 'phalanges are rare, the commonest being at the metatarsophalangeal joint of the great toe. Dislocations at the metatarsophalangeal joints of the other toes and of the terminal phalanx of the great toe have been reported, but are exceedingly rare. In all of these dislocations the diagnosis is made without difficulty in the absence of great swelling. When this is present, an a-ray examination will serve to establish it. Treatment. — The treatment should consist in traction and direct pressure over the displaced bone. CHAPTER XXXI. HERNIA. The term Hernia is used to signify the protrusion of an organ from the cavity in which it is normally contained, as hernia cerebri, following trauma. When this term is unqualified, it is understood as denoting a protrusion from the abdominal cavity, through a weakened portion of the wall, .and implies a pouching of the containing wall forming a continuous covering for the displaced contents. To facilitate the discussion of this condition, it will be profitable to review very briefly certain transitory conditions, which exist during embryonic life, and the structure of the containing walls of the abdominal cavity, as they exist in the adult. Embryology. — Until the end of the eighth week of fetal life, the testicles and ovaries have occupied a position well forward in the abdominal cavity, and at the beginning of the third month, lie opposite the lumbar vertibrce. From this time until birth, they gradually move toward the position which they will occupy in the adult. In the latter part of the second, or beginning of the third month of fetal life, at the point where the gubernaculum pierces the body wall, there is an evagination of the peritoneum, knowm as the processus vaginalis peritonei. The evagination is for a time a shallow depression, but gradually increases in size and accompanies the gubernaculum to its lower point of attachment. During the ninth month, in the male, the testicle descends beside the processus vaginalis, through the inguinal canal, and comes to lie in the scrotum. Normally the pro- cessus vaginalis becomes shut off just above the testicle and forms a partial serous investment for that organ, known as the tunica vaginalis, and that portion of the processus vaginalis lying between the internal ring and the tunica vaginalis becomes completely obliterated. Deviations from the normal occur (Moschowitz) . Among them are : 1. The processus vaginalis may remain open in its entire extent. 2. The processus vaginalis may close off at its lower end, forming a complete tunica vaginalis for the testis, but it remains patent at the internal ring. 3. The processus vaginalis may remain open at its lower end but becomes shut off at its upper end. 4. The processus vaginalis may form the tunica vaginalis as is normal, and may also become shut off at the internal ring, but the intervening portion does not become obliterated. 5. The processus vaginal may form the normal tunica vaginalis, and the upper part becomes shut off at or in the neighborhood of the 910 HERS I A external inguinal ring, while the most superior portion remains patent and communicates with the general peritoneal cavity. 6. The processus vaginalis may begin the shutting off of the normal tunica vaginalis, but the process may stop before it is entirely com- pleted. In other words, the sac may not improperly be compared to an hour-glass open at its top, the size of the two halves varying. If the processus vaginalis remains patent in the female it is known as the canal of Xuck. Incomplete obliterations of the processus vaginalis may give rise to cystic swellings, known as hydroceles of the cord or round ligament. Anatomy. — For detailed anatomy, the reader is referred to special works upon the subject. There are a few structures, however, with the relationship of which it is necessary to be familiar to understand the morbid anatomy of the subject under consideration. The two structures which do most to protect the potential weakness which exists in the inguinal region are the internal oblique muscle and the transversalis fascia. In a well-developed subject the lower part of the internal oblique muscle consists of a thick mass of fibres which arise from the outer half of Poupart's ligament, and pass horizontally to their insertion in front of the rectus. The question as to whether a person will develop a hernia in this region depends largely upon the development of this muscle and it- relation to other structures, especially Poupart's ligament. Blake has called attention to the fact that " if Poupart's ligament takes a horizontal direction as in the female, the internal oblique coincides with it and there is consequently a strong inguinal region, but if, as in some males with deep and narrow pelves, Poupart's liga- ment takes a more oblique course, there is an unprotected triangular space, bounded cephalad by the internal oblique, mesad, by the margin in the rectus, and caudad, by Poupart's ligament, which may be called the undefended space, and through which hernia is apt to occur, especially the direct variety, when the structures become relaxed by age." In the inguinal region, the transversalis fascia in the region of the internal ring is made up of strong fibres, curving in a sling-like manner about the inner and lower border of the ring, the so-called inguinal ligaments of Henle. Just across the inner side of the deep epigastric artery, at the usual site of a direct inguinal hernia, is a weaker portion of this fascia, which further toward the midline is made up of strong vertical fibres. Neither the transversalis muscle nor the conjoined tendons are important factors in preventing the occurrence of, or in repairing an exi-ting, hernia. Nerves. — As it is frequently desirable to operate upon inguinal or femoral hernia under local anesthesia alone or in combination with nitrous oxide and oxygen, an accurate knowledge of location of the THE SPERMATIC CORD 911 nerves supplying this region is essential. Braun has described the innervation of this region as follows: "The external spermatic nerve, which is a branch of the genitocrural, joins the spermatic cord at the internal ring, and accompanying it, emerges from the inguinal canal on the under surface of the cord. "The ilio-inguinal nerve lies above the spine of the ilium, between the oblique abdominal muscles, passing under the fascia of the external oblique, it leaves the inguinal canal on the anterior surface of the hernial sac or the spermatic cord. "The iliohypogastric runs almost parallel with and a little higher than the former, between the oblique abdominal muscles, and in the inguinal region under the aponeurosis of the external oblique muscle. It penetrates the anterior sheath of the rectus, in this manner reaching the subcutaneous tissues, innervating the skin of the inguinal region." As these three nerves form a plexus in their ultimate distribution, one or even two of the main trunks may be absent — all of the fibres being carried by the remaining nerve. Cushing has called attention to the fact that if the three nerves first mentioned are blocked at their entrance into the inguinal canal, the greater part of the field will become insensitive. Bloodvessels. — The course of the deep epigastric artery may be indicated on the surface of the body by a line drawn from the middle of Poupart's ligament toward the umbilicus. Shortly after this line crosses the linea semilunaris the direction changes and the vessel is directed cephalad in the line of junction of the inner third with the outer two-thirds of the rectus muscle. This vessel arises just above Poupart's ligament from the external iliac; as it curves forward it lies in the extraperitoneal fat, turns around the lower border of the peritoneal sac, and runs upward and inward along the inner side of the internal abdominal ring, and along the outer border of Hesselbach's triangle. Obturator Artery. — In about 30 per cent, of the cases the obturator artery instead of arising from the internal iliac is given off from the deep epigastric artery, in which case it must descend nearly vertically to enter the upper part of the obturator foramen. In its descent to this foramen it usually passes downward on the lateral aspect of the crural canal in contact with the external iliac vein. However, in 3 per cent, of all cases, it passes downward along the free edge of Gim- bernat's ligament, and thus almost completely encircles the neck of an existing femoral hernial sac, and might be subject to injury in division of the structures about its neck. The Spermatic Cord.— The spermatic cord is composed of the vas deferens, the artery of the vas, the veins of the vas, the spermatic artery and spermatic veins proper, the sympathetic nerves and the lymphatics; these are all surrounded by the infundibuliform fascia, the cremasteric fascia and muscle, and the intercolumnar fascia. The spermatic artery is a branch of the aorta, and the artery of the 912 HERNIA vas is a branch from the superior or middle vesical artery. Either one can be ligated without interfering with the function of the testicle (Bevan). The veins may be divided into two groups: an anterior and a poste- rior, the former accompanying the spermatic artery and emptying, those on the right side into the ascending vena cava, on the left, into the renal vein. The posterior group accompanying the artery of the vas empties largely into the deep epigastric veins. The vas deferens can be readily distinguished from the other structures in the cord by its hard, firm consistence. Etiology. — Two factors are always present in a given case of hernia, a weakening of the abdominal wall, which predisposes the individ- ual to the disease, and the occurrence of increased intra-abdominal pressure, which acts as the exciting cause. Coley states that in the vast majority of cases hernia is due to a congenital defect or an abnormal size of some normal opening in the abdominal wall. He considers the congenital defect the main cause, while the exciting cause plays a minor role. R. Hamilton Russell, who has studied at great length the embryology of this condition, goes so far as to say that oblique inguinal hernia is invariably caused by the presence of a congenital sac, which is produced by the patency of the whole or a part of the processus vaginalis. That even a direct hernia may have a preformed sac was demon- strated by Russell, who has a specimen of a direct inguinal sac, asso- ciated with an open funicular process in the same side, which was taken from a man who had never been the subject of hernia. In femoral hernia there may be an abnormally large femoral ring, but here, too, Russell believes that there may be a congenital preformed sac; Incomplete union of the structures about the umbilicus is a predisposing cause of hernias in this region. Other predisposing causes which should be mentioned are: Heredity, age, sex, pregnancy, obesity, atrophic changes, and trauma. Heredity. — McCraedy states that 25 per cent, of the patients with hernia give a family history of this condition. Age. — The majority of patients are between the age of twenty-one and fifty. Sex. — The relative frequency has been variously estimated by differ- ent authors as occurring between 75 to 84 per cent, in males, 25 to 16 per cent, in females. The predominance of males has been ex- plained on the basis of the greater frequency of inguinal hernia in the male, and by the role played by occupation as an exciting cause. Pregnancy. — The stretching and the subsequent relaxation of the abdominal wall, due to pregnancy, ascites, or obesity is a predisposing cause of hernia, especially the umbilical type, and that associated with a diastasis of the recti. CLINICAL CLASSIFICATIONS 913 Atrophic Changes. — Atrophic changes as occur with senility or with wasting constitutional diseases. Trauma. — There may be a formation of cicatricial tissue, following local injury or surgical operations; or nerve lesions caused by trauma, resulting in the atrophy of muscles they innervated. Exciting Causes. — Any condition which produces increased intra- abdominal pressure may act as an exciting cause. Thus, occupations necessitating heavy lifting or straining are factors; also coughing, parturition, obstruction to urination, constipation, abdominal tumors or ascites. The constituent parts of a hernia are the sac, contents and cov- erings. The sac consists ol peritoneum, its shape depends upon the shape of the opening, through which it penetrates the abdominal wall, and the degree of restraint offered by the overlying tissues: thus an umbilical hernia is apt to be globular; an inguinal hernia which has not descended beyond the external ring sausage-shape; while one that has descended into the scrotum may be pyriform. Sacculations may exist in the sac wall, or be due to constrictions of overlying bands of tissue. According to Russell, "All of the multitudinous varieties of inguinal hernia owe their origin to the corresponding varieties of sacculation of the sac." Not infrequently some of these sacculations become encysted (hydrocele of the sac). The contents vary. Almost every abdominal organ has at some time been noted as present in a hernial sac. The most frequently noted contents are omentum, and intestine. A hernia containing omentum alone is called an epiplocele, one containing intestine alone, an enterc- cele, while one containing both is termed an entero-epiplocele. The coverings of a hernia vary with the site, and usually consist of fascia and skin. Clinical Classifications. — Clinically, hernias are designated as redu- cible, irreducible, inflamed, obstructed, and strangulated. A reducible hernia is one in which the entire contents of the sac can be reduced into the abdominal cavity without a cutting operation. An irreducible hernia is one in which the contents of the sac cannot be completely reduced into the abdominal cavity without a cutting operation. The cause of the irreducibility may be: 1. Adhesions between the contents (usually omentum) and the sac wall. 2. Adhesions between the contents of the sac, as between intestine and omentum. 3. Bulk of sac contents (too great to be returned to the abdominal cavity). 4. Increase in the size of the sac contents (thickened edematous omentum). 58 014 HERNIA 5. Sliding hernias — where part of the sac is formed by the wall of the gut. An inflamed hernia is one in which a local peritonitis exists in the sac. It is frequently produced by prolonged taxis, or an ill-fitting truss, but may be caused by enteritis or obstruction. An incarcerated or obstructed hernia is one in which there is interfer- ence with the passage of the bowel contents but without interference with the circulation. The obstruction is not necessarily complete, as gas is frequently passed. It is most common in hernia containing large intestine. A strangulated hernia is one in which there has been both an interfer- ence with the blood supply of the intestine and with the passage of bowel contents. The mechanism of strangulations has been the subject of investiga- tion since the condition was first recognized, and many conflicting hypotheses have been advanced as to its causation. The term "elastic strangulation" has been given by the Germans to a mechan- ism of strangulation, first suggested by Wilmes as early as 1788, and subsequently amplified by Manchart. According to this theory, when a loop of bowel is forced through a narrow hernial aperture or when more bowel is driven down into a hernia already protruding, there is a disproportion between the protruding parts and the ring. The opening during the passage of the gut is dilated to its utmost, it then recoils and compresses the intestine, thus producing a strangu- lation. "All subsequent theories of strangulation which have been put forward to supplement or to supplant that of elastic strangulation, have been chiefly of academic interest and affect in no way the rules of treatment. Most of them rest upon the assumption that the pressure within the bowel above the sac, or in the sac, may be suddenly raised by a down-rush of intestinal contents, and this rise of pressure in one way or another causes obstruction" (Macready). Morbid Anatomy. — When interference with the circulation of a hernia takes place, it usually comes about gradually. In exceptional cases the disproportion between the hernal aperture and the protru- sion may be so great that the arterial and venous streams are both immediately stopped. Most commonly the venous circulation is the first to be retarded, and is manifest by the dark red or bluish and edematous appearance of the gut wall and the transudation of clear serum into the sac. Gare has pointed out the fact that the fluid in the sac of a non- strangulated hernia is absolutely sterile. There are two conditions under which one may not be able to demonstrate fluid in the sac of a strangulated hernia : First, there may be a complete absence of fluid, due to a complete and immediate stopping of venous and arterial circulation. Second, due to adhesions between the viscera and the front of the sac; the fluid may be collected at the back of the sac (Macready). MORBID ANATOMY 915 If the interference with the circulation is continued the color of the gut becomes purple and later gray or black. The peritoneal covering loses its lustre and becomes granular in appearance, but in this connec- tion it must be remembered that the lustre of the serous coat may be dimmed by an inflammatory process, though the loop is still viable. For a time it may be possible to demonstrate the pulsation of mesenteric vessels supplying the protruding loop or when the bowel is stroked, the vessels may be emptied and seen to refill, or if still living, the gut wall will bleed if pricked; but as gangrene supervenes, these signs are lost. There is frequently a thrombosis of the mesenteric vessels of sufficient extent to compromise the circulation of segments of intestine within the abdominal cavity. The fluid in the sac which at first was clear and odorless, may successively become reddish brown, dark brown, or coffee-ground color, and take on a foul odor. The foul odor is not in itself to be taken as a sign of gangrene. In late stages the fluid is found to contain various pathogenic organisms, which have found their way through the damaged gut walls. The intestinal wall loses its power of contractility, is of lower temperature than the surrounding tissues and frequently becomes distended with gas and fluid. Its surface may be covered with fibrin. Where great or prolonged pressure has been exerted at the point of stricture, the various coats of the intestine become necrosed and give way. Micaise has called attention to the fact that they give way in the following order: (1) The mucous membrane, (2) circular mus- cular fibres, (3) longitudinal muscular fibres, (4) the strong connective layers of the intestine, (5) the serosa. If this condition is not relieved by operative interference it may terminate in any one of several ways. The strangulated loop may rupture into the hernial sac, or a local peritonitis exist in the sac, due to the migration of pathogenic organisms from the lumen of the gut; either of these conditions may result in the coverings of the sac being involved in the inflammatory process, with subsequent rupture, allowing the escape of the sac contents and the establishment of an artificial anus. There may be an extension of the peritonitis in the hernial sac to the general abdominal cavity, or the above-mentioned thrombosis of mesenteric vessels supplying intra-abdominal segments of intestine may occasion a primary peritonitis in the abdominal cavity. In cases not relieved by operation, the cause of death in the vast majority of instances is the existence of a peritonitis or an overwhelming toxemia from stasis. The length of time which intervenes between the onset of strangula- tion and gangrene of the gut is dependent upon a number of factors: the tightness of the stricture, the age and general condition of the patient, and according to Macready, the distance below the stomach of the part strangulated. Cases have been observed in which gangrene 916 HERNIA was present four hours after the onset of strangulation; "it is rare before twenty-four hours, and is delayer! by the pressure of omentum in the sac" (Blake). CLINICAL VARIETIES OF HERNIA. Reducible Hernia. — Symptoms. — Many of this variety give a history dating from birth or shortly after with a gradual increase in size; others appear gradually in adult life and may be unobserved by the patient until they have attained considerable size; still another group are brought to the patient's attention for the first time following some effort or strain and are usually accompanied by sharp, lancinating pain. The majority of cases in this group, however, complain only of a dragging pain or a .sense of fulness at the site of the hernia; occasionally where the hernia is large, reflex gastric or intestinal symptoms may be present. Depending upon the site and the size of the tumor, inspection usually reveals a mass which descends or increases in size upon standing or coughing, and may be spontaneously reducible upon the patients assuming a recumbent position. In practically all of these cases a distinct impulse upon coughing or crying is palpable, and the examining hand may be able to determine the contents of the sac either at the time when it is driven down by the impulse of coughing, or as it slips back under the examining fingers as the patient assumes a recumbent position. In enteroceles there is usually a characteristic gurgling to be felt and sometimes heard, while the epiploceles have in most cases an easily recognizable irregular or nodular feel. Many cases which are not spontaneously reducible may be reduced by gentle manipulation on the part of the surgeon. Percussion over an enterocele elicits a tympanitic note, while that over an epiplocele gives a dull or flat note. Treatment. — Unless there are special contra-indications, as will be pointed out in the discussion of the anatomical varieties, hernias of this group are best treated by operation for the radical cure of the con- dition. Where such contra-indications exist they should be treated by a mechanical support or truss. Irreducible Hernia. — The early history in this group of cases is usually that of a reducible hernia, which has either been neglected by the patient or subjected to repeated trauma of an ill-fitting truss or forcible taxis, with the end-result that it is no longer spontaneously reducible and cannot be reduced by any effort on the part of the patient or surgeon. Symptoms. — The symptoms of this group differ from the preceding only in the point of irreducibility, and in their greater tendency to become obstructed. Ninety per cent, of all irreducible hernias contain omentum (Macready). CLINICAL VARIETIES OF HERNIA 917 Treatment. — Unless there be marked contra-indication against sub- jecting the patient to any operative procedure, operation should be promptly carried out in this group of eases. In the cases in which the size of the hernia precludes the possibility of its return to the abdominal cavity or in which operative contra- indications exist, a belt or truss which will support the hernia and prevent any increase in size is indicated. Inflamed Hernia. — There is always an antecedent history either of a reducible or irreducible hernia, which in most instances has been trau- matized by truss or taxis, so that it presents in addition to the symp- toms of its original condition, those of pain, tenderness, redness, and edema over the site of protrusion, frequently accompanied by con- stitutional symptoms of fever and malaise. There may be vomiting and constipation. Treatment. — Immediate operation is indicated. Obstructed Hernia. — In this group of cases usually there is an antecedent history of a large reducible or irreducible hernia in a patient who has suffered from constipation. Symptoms. — The onset of the obstruction is coincident with an increase of constipation which becomes marked but usually not complete, as gas may be passed. The abdomen gradually becomes distended and vomiting ensues late and usually is not severe and not fecal in character. There is an increase in the size of the protrusion, and a hernia which formerly may have been reducible becomes irre- ducible. The impulse upon coughing can still be obtained best near the neck of the sac. The hernia becomes painful, and of somewhat doughy consistency. The percussion note varies, depending upon the presence or absence of gas, from dulness to tympany. If this condition is not relieved, strangulation frequently super- venes. Treatment. — Relief may be had in some cases by resorting to enemata and taxis. If relief is not speedily forthcoming, operative intervention should be instituted. Strangulated Hernia. — Symptoms. — There is usually a history of a previously irreducible hernia, which may have become inflamed or obstructed; but one must not lose sight of the fact that it is possible for a hernia to become strangulated at the time of its first appearance. The onset of strangulation is abrupt and is usually accompanied by profound shock. Pain is present, is severe and colicky in character, and is frequently referred to the region of the umbilicus. With the onset of the pain, the patient is nauseated and vomits, the vomitus consisting first of stomach contents and bile-stained fluid. Constipa- tion is absolute, neither gas nor feces are passed. As the condition progresses, there may be a continuation of the initial vomiting, which is probably reflex in character, or there may be a free interval between this and the vomiting of obstruction which is fecal in character and comes on later, at a variable time, depending 918 HERNIA upon the portion of the intestine which is strangulated; the lower in the intestinal canal that the obstruction exists, the later the vomiting. With the onset of gangrene there is a subsidence of the pain, and usually of the initial reflex vomiting. The abdomen becomes distended, the degree of distension depending upon the site of obstruction; the lower the obstruction the greater it will be. Locally. — There is pain and tenderness at the site of the protrusion. There is an increase in size of the hernia which becomes more tense. Impulse is lost. (Where the strangulation is due to a band within a hernial sac, an impulse may be obtained from the non-strangulated portion of the sac.) In rare cases the overlying skin may become red and infiltrated. The pulse is rapid and later becomes feeble and irregular. Tempera- ture may be subnormal or slightly elevated at the onset, but rises later with the onset of gangrene. ] J i rita/it/j?n ! , Vt/st/c & fascia : Skirt & Subcutaneous Fig. 442. — Partial enterocele, or Richter's hernia. (Ashhurst.) In certain varieties of strangulated hernia, the typical symptoms may not be elicited. Eccles has tabulated a group of conditions under which strangulation has been found to exist accompanied by atypical symptoms. This tabulation subsequently modified by Blake is as follows: I. Cases in which the peculiarities are dependent upon the contents of the sac. 1. Strangulation of a portion of the bowel. (a) Partial enterocele (Richter's hernia) (Fig. 442). (b) Strangulation of the vermiform appendix. (c) Strangulation of Meckel's diverticulum (Littre's hernia) (Fig. 443). In this group the obstructive symptoms are usually absent. 2. Strangulation within the body of the sac. (a) By bands, adhesions, apertures in the omentum, etc. (b) By kinking or volvulus. CIJX/CAL VARIETIES OF IIEh'XIA DID II. Cases in which the peculiarities are dependent upon the sac. (a) Strangulation within a loculus or a pouch within the sac. III. Retrograde incarceration or hernia "En IT." — In this condition the two lateral limbs of the " W" are formed by segments of gut in which the circulation is normal or but slightly impaired and which lie in the sac, while the middle or connecting loop of the "W" lies within the abdomen and is gangrenous, its mesentary being constructed at the neck of the sac. It may be found difficult to diagnosticate properly the existence or site of strangulation under any of the following conditions: 1. Where a strangulated hernia is present at one hernia site and an irreducible hernia at another. Both hernias may have existed for some time, or one may be recent and strangulated at the time of its occurrence. 2. Where there is an irreducible hernia in a patient with obstruction or strangulation from some other intra-abdominal cause. Fig. 443. — Littre's hernia — a hernia of one of the intestinal diverticula (Meckel's diverticulum) . (Ashhurst.) 3. Where one hernia conceals another, as a large and a small epigastric hernia situated close together. 4. Where there is an inguinal and a femoral hernia on the same side, one strangulated, and the other not. The local physical signs, however, are usually sufficient to indicate which hernia is strangulated where two or more hernias coexist. Treatment. — Treatment is either by taxis or by repair of the hernia. Taxis. — By taxis is meant the replacement of the hernial protrusion by manipulation. Reduction by this means may be facilitated by a posture which would permit gravity to act and would also help to obtain muscular relaxation at the site of the hernia, i. e., in inguinal or femoral hernia, these conditions would be fulfilled with the patient in the dorsal position with the foot of the bed raised, with the thigh rotated inward and flexed upon the pelvis. Muscular relaxation also may be obtained by immersing the patient in a warm bath, or best by the administration of an anesthetic. In 920 HERNIA addition to the above, support of the neck of the sac with one hand while gentle pressure is exerted over the fundus of the sac with the other in the direction of the canal through which the sac escaped, is frequently enough to effect a reduction. Taxis should always be carried out with the greatest possible gentle- ness and never should be prolonged over five minutes. There are certain dangers associated with taxis which should be appreciated, among them are: 1 . Rupture of gangrenous gut, or rupture or damage to the gut which was still viable at the time taxis was performed. 2. Return of a segment of non- viable gut to the abdominal cavity. 3. Return of septic contents of the sac to the peritoneal cavity. 4. Reduction en masse without the relief of the constriction at the neck. There are certain conditions under which taxis should not be attempted . These are : 1. Where the hernia was known to be irreducible previous to the onset of strangulation. 2. Where it has been tried once and failed. 3. Where the patient is in a condition of profound shock. 4. YN here there is reason to believe the gut is gangrenous, or where the strangulation has existed for twenty-four hours. 5. Where the superficial tissues are inflamed. Operative Treatment. — This is the procedure of choice in a case of strangulated hernia. Where the condition of the patient is such that the administration of a general anesthetic is thought unwise, many cases can be successfully operated upon under local anesthesia alone, or sup- plemented with the administration of morphine. Open operation per- mits of inspection of the strangulated loop, the removal of obstacles to reduction, the determination as to the viability of the strangulated loop and also of adjacent intra-abdominal segments, the prevention of septic contents being returned to the peritoneal cavity. The prevention of reduction en masse, resection of gut if necessary, and it also permits the radical cure of the hernia. Procedure. — The coverings of the sac are divided by an incision similar to that which would be made for the radical cure of the hernia, thus exposing the sac, which is carefully opened, allowing any fluid to escape and permitting a full view of the contents, which should be flushed with sterile salt solution to minimize the danger of contami- nating the peritoneal cavity. The constriction causing the strangulation is next divided and the contained and adjacent proximal and distal segments of gut drawn downward and examined to determine their viability. If the condition of the gut is satisfactory it may be returned to the abdominal cavity and the operation for the radical cure completed. If the intestine is obviously gangrenous or damaged to such an extent that its return is deemed unsafe, one of two procedures may be carried out: resection ANATOMICAL VARIETIES OF HERNIA 921 with reunion immediately, or the establishing of an artificial anus. Statistics prove the first of these procedures to be preferable. There is a third group made up of those cases in which upon opening the sac there is doubt in the operator's mind as to whether the gut is viable or not. In these cases the relief of the constriction and the surrounding of the suspected loop with sterile pads moistened with hot saline for five or ten minutes will frequently determine the procedure. In case a resection is indicated in a strangulated femoral hernia it will be found more convenient to carry out this procedure through a separate abdominal incision, preferably through the rectus. ^ ■ mSSm ■ Fig. 444. — Hydrocele and inguinal hernia. ANATOMICAL VARIETIES OF HERNIA. Anatomically hernias are designated as inguinal, femoral, umbilical; ventral hernia of the linea alba, (a) epigastric, (6) hernia below the umbilicus; diastasis of recti; traumatic ventral hernia; hernia of the linea semilunaris; lumbar, ischiatic, diaphragmatic, obturator hernia of the pelvic outlet; and hernia through the linea transversa?. Inguinal Hernia. — This term refers to all hernias through or into the inguinal canal. They may be subdivided into three groups: (1) indirect or oblique, (2) direct, and (3) interstitial. Indirect or Oblique Inguinal Hernia. — This is the commonest variety of inguinal hernia, constituting 93 per cent, of the hernias in this region. Most recent authors agree that in "the vast majority of inguinal 922 HERNIA hernias in the male, and practically all in the female, the sac is pre- formed, there being an open funicular process of peritoneum existing at birth, though the hernia may not develop until adult life." Fig. 445. — Congenital hernia. Fig. 446.— Infantile hernia. Fig. 447. — Acquired hernia. The term congenital hernia has been applied to those cases in which the hernia descends into the unobliterated processus vaginalis, in either the male or female. Fig. 448. — Left inguinal hernia. The term infantile hernia is used to designate that type of acquired hernia in which the sac formed from the parietal peritoneum protrudes from the side of the patient or partially obliterated processus vaginalis. In the ordinary acquired variety of oblique inguinal hernia the protruding viscus in its descent through the inguinal canal pushes in front of it, not only its own sac of peritoneum and fatty tissue, but also a process of the transversalis fascia and the cremasteric fascia. ANATOMICAL VARIETIES OF HERNIA 923 As it emerges from the external abdominal ring it enters the process of the intercolumnar fascia which incloses the cord, and finally descends into the scrotum, where it is covered by the dartos and skin (Fig. 4 48). This is the adult type of the disease. An indirect hernia is said to be incomplete {bubonocele) when the protrusion occupies the inguinal canal. It is called complete or scrotal in the male, and complete or labial in the female, wdien it reaches the bottom of the scrotum in the male or labium in the female. Diagnosis. — The subjective and objective symptoms of a reducible hernia (see above) are usually present. It may be necessary to differentiate an incomplete indirect hernia from any of the following Fig. 449. — Large scrotal hernia. (Richardson.) conditions: Hydrocele of the cord or canal of Nuck, femoral hernia, inguinal adenitis or abscess, psoas abscess, new growth of the inguinal glands, undescended testicle, lymphangiectasis of the inguinal lym- phatics secondary to filariasis. A complete indirect hernia may be confused with the following: a hydrocele of the tunica vaginalis, varicocele, hematocele, inflam- matory conditions of the testis, and epididymis, new growths of the testicle and epididymis. Treatment. — Treatment may be either by mechanical means, such as a truss, so arranged as to exert an even pressure over the point of exit of the hernia, i. e., over the internal ring; or by an operation for the radical cure. Mechanical treatment gives its best results where it is 924 HERNIA used during the first year of life; a spring truss being most effective in infancy. Later in life treatment by mechanical means is best reserved for those eases in which there is some contra-indication to operation. Operation for the Radical Cure of Inguinal Hernia. — Many operations have been devised for the cure of this condition but none have stood the test of time as well as the Bassini which, with slight modifications adapted to an individual case, is best suited to give uniformly satis- factory results. The steps of the operation are as follows: An incision is made 2 cm. above Poupart's ligament and parallel with it, beginning at a point corresponding to the internal ring and extending to the centre of the external ring. The structures are divided down to the aponeurosis of the external oblique muscle and the external ring exposed. A grooved director is then passed into the canal from the external ring, and upon this the aponeurosis is split in the direction of its fibres for a distance of 5 to 7 cm. The upper flap of the aponeu- rosis is next stripped from the internal oblique and the sheath of the rectus for a distance of 2.5 to 3.5 cm. This separation makes it easier subsequently to bring down the lower edge of the internal oblique. Fig. 450.- — Spring truss. The lower flap is next freed on its under surface from the coverings of the cord and sac, and the shelving border of Poupart's ligament is well exposed as far as its insertion. The sac is then exposed at its uppermost portion, the overlying cremasteric and transversalis fascia being divided by sharp dissection, which is continued until the neck of the sac is isolated from the cord. This accomplished the remainder of the sac may be separated from the cord by pushing with gauze or by sharp dissection. Any bleeding vessels should be instantly ligated and the cord handled with extreme gentleness to avoid subsequent swelling. After the sac is freed from the surrounding tissues it is opened and the contents reduced. Existing adhesions should be divided and redundant, inflamed or damaged omentum resected after a chain ligation. The sac is now exposed to insure its emptiness, its neck drawn outward and securely ligated with a transfixation suture of catgut (Fig. 451), the distal portion removed (except in congenital hernia, where the lower portion is ligated or sutured to form a tunica vaginalis for the testicle), the stump is allowed to sink into the abdominal cavity. Sometimes the neck of the sac is so bulky or of ANATOMICAL VARIETIES OF HERMA 925 such shape that ligation is impossible. In these cases the neck of the sac is closed by suture and the distal portion removed. The cord is now freed and retracted to the outer part of the wound. Several deep sutures of Kangaroo tendon or chromicized catgut are Fig. 451. — Operation for the radical cure of inguinal hernia (Bassini's method): a, sac dissected from the cord, opened, examined, and neck ligated; b, cord; c, Poupart's ligament; d, arched fibres of internal oblique muscle; e, transversalis fascia. (Bryant.) Fig. 452. — Operation for the radical cure of inguinal hernia (Bassini's method) : sac removed (c), cord drawn aside, and stitching of lower fibres of the internal oblique and transversalis muscles (6) to Poupart's ligament (d) from without inward; o, trans- versalis fascia. (Bryant.) then passed through the whole thickness of the lower border of the internal oblique and the deep layer of Poupart's ligament, the first stitch being taken on the inner side of the cord in such a manner that J)2(i HERNIA the suture should just touch the cord when it is held up at right angles to the wound. The remaining sutures, usually three or four in number, unite the internal oblique and Poupart's ligament as far as the spine of the pubis, where the inner portion of the internal oblique is deficient. The last stitch can include the conjoined tendon and the margin of the rectus (Figs. 452 and 453). After the structures are snugly drawn together and the sutures knotted, reconstructing the floor of the inguinal canal, the cord is allowed to drop into place. Some operators put a suture on the outer side of the cord with the idea of giving the muscular fibres a lower plane at their origin, and placing the point of emergence of the cord at a greater distance from the internal abdominal ring, giving the latter Fig. 453. — Operation for the radical cure of inguinal hernia (Bassini's method): arched muscular fibres and conjoined tendon (b) sewed to Poupart's ligament (a); c, aponeurosis of external oblique muscle. (Bryant.) additional protection. When this suture is used it should be the first to be introduced and tied. The roof of the canal is now made by uniting the divided external oblique aponeurosis with a continuous suture of fine catgut which should be carried down to a point which leaves only enough of the external ring open to allow the cord to pass outward without con- striction (Fig. 454). The skin wound is closed and the dressing ap- plied. Some operators have modified this technic by allowing the cord to remain beneath the deep layer of sutures uniting the internal oblique muscle to Poupart's ligament, emerging at the external ring. This modification should be used where the transversalis fascia forming the dorsal wall of the inguinal canal is well developed, as is apt to be the case in small and oblique hernia, and when the internal ANATOMICAL VARIETIES OF HERNIA 927 oblique muscle is well developed and can be easily brought down to Poupart's ligament. Adult patients should remain in bed from three to four weeks. Children under fourteen years of age from two to three weeks. Ilalsted's operation differs from the Bassini procedure in that he divides the fibres of the internal oblique above the internal ring, draws the cord outward at the upper angle of the wound, unites all the deeper tissues, fascia muscles and aponeuroses to Poupart's ligament by a single row of mattress sutures of silver wire, removes the superficial veins of the cord and allows it to pass from the upper angle of the wound to the scrotum between the muscles and the skin (Fig. 455) . Fig. 454. — Operation for the radical cure of inguinal hernia (Bassini's method) : aponeurosis of external oblique (a) sewed with continuous sutures to Poupart's ligament (b). (Bryant.) • Bloodgood's operation is a modification of Halsted's and consists in exposing the outer fibres of the rectus muscle by a division of the posterior layer of the sheath, and including it in the lower three or four deep sutures, thus reinforcing the often thin and weakened fibres of the internal oblique (Fig. 456). Direct Hernia. — Direct hernia is comparatively rare, the protrusion taking place through Hesselbach's triangle or that space in the lower abdominal wall bounded by the sheath of the rectus muscle, the deep epigastric artery, and Poupart's ligament. If the protrusion occurs in the outer half of this space, between the epigastric and the obliterated hypogastric artery, the hernia will have practically the same coverings as an oblique inguinal hernia, if it occurs through the inner half of the space it may carry with it a tunic made up of the denser portion of the transversalis fascia, with or without a few fibres 928 HERNIA of the conjoined tendon, or it may force its peritoneal and subperitoneal coverings beneath or between the fibres of this structure and receive only an investment of the intercolumnar fascia. In the direct hernia the sac generally lies behind or to the inner side of the cord, and the two may not be contained in the same fascial sheath. Fig. 455. — Operation for the radical cure of inguinal hernia (Halsted's method): veins ligated and resected; silver sutures inserted, one above and four below the cord. (Bryant.) This type of hernia constitutes about 7 per cent, of the inguinal hernias, is more common in men than in women and is seldom complete. Treatment is the same as for the indirect variety with the exception that where there is a large undefended space, as frequently occurs in direct hernia with the lower border of the internal oblique a con- siderable distance above Poupart's ligament. Blake has transplanted ANATOMICAL VARIETIES OF HERNIA '.)_". I the rectus muscle, exposing the muscle by the Bloodgood method of slitting its deep or dorsal sheath, has sutured the rectus to Poupart's ligament first and then brought the internal oblique down in front of it, as in the Bassini operation. The reason for this pro- cedure is that bringing down the rectus lowers the insertion of the ATTACHMENT OF RECTUS'" TO SYM. PUB. SPINE PUB! Fig. 456. — Operation for the radical cure of inguinal hernia (Bloodgood's modifica- tion of Halsted's method); cord removed so as not to obscure demonstration: a, a, divided borders of internal oblique muscle; b, b , ends of resected cord. (Bryant.) internal oblique, thus permitting the suturing to Poupart's ligament with much less tension. Interstitial Hernia. — This is a form of hernia in which the protruded mass in its descent does not follow the direction of an ordinary inguinal hernia but is found to occupy one of three locations: 59 o:;o HERNIA 1. Between the internal oblique and the aponeurosis of the external oblique. 2. Between the external oblique aponeurosis and the skin. 3. Between the peritoneum and the transversalis fascia (projieri- loneal hernia). Occasionally two distinct but communicating sacs are present, one entering the scrotum in the usual manner and the other in one of the abnormal situations just described. In many cases of the third variety where the protrusion exists between the peritoneum and the Fig. 457. — Operation for the radical cure of inguinal hernia (Bloodgood's modifi- cation of Halsted's method) : the transplanted border of the rectus united to Poupart's ligament, showing slight change in the direction of its fibres. (Bryant.) transversalis fascia, no tumor is present, and exact diagnosis is often impossible before operation. Associated with this variety there is, in the majority of cases, a scrotal or labial hernia. Occasionally a preperitoneal hernia is produced by the apparent reduction of an incarcerated inguinal or femoral hernia, the so-called reduction en masse, the entire sac and its contents being pushed backward through the ring between the muscles and the parietal peritoneum where it remains still constricted by the neck of the peritoneal sac. ANATOMICAL VARIETIES OF HERNIA 931 The frequency with which interstitial hernia is associated with an undescended testicle has been variously estimated by different authors. Macready states that 67 per cent, of the cases occurring in males are accompanied by a wholly retained or partially descended testicle. While in those cases in males observed by Langdon 95 per cent, showed an undescended testicle. " The most characteristic point of all forms of interstitial hernia is their association with some form and degree of crypt orchidism" (Moschowitz) . Femoral Hernia. — This variety of hernia is less frequent than the inguinal, the proportion being about one of the femoral to seventeen of the inguinal. It rarely occurs as a congenital affection, and is generally observed in adult females. The stretching of the fascia in this region by repeated pregnancies and the fact that the canal is larger in women, constitute predisposing causes for this sex. A femoral hernia has been known to follow an operation for the repair of an inguinal hernia because of the pulling up of Poupart's ligament by the muscles sutured to it, thus enlarging the canal. The protrusion leaves the abdominal cavity at a point just beneath Poupart's ligament and to the inner side of the femoral vein. It enters a membranous pouch called the femoral canal, which is the inner compartment of the femoral sheath. This canal extends down- ward by the side of the femoral vein to the saphenous opening of the fascia lata. (In rare instances the hernia may descend in front of the vessels or even on their lateral aspect.) In its descent the sac of the hernia carries before it a thickened pouch of the subserous cellular tissue, called the septum crurale. As it emerges at the saphenous opening it also receives an investment from the cribriform fascia. Recently developed femoral hernias may be covered only by the skin, superficial fascia, and a single layer of dense membrane, called by Cooper the fascia propria which results from a fusion of the septum crurale and the cribriform fascia. In long-standing cases dissection will occasionally reveal several layers which are probably the result of an inflammatory process. The neck of a femoral hernia is in relation anteriorly with Poupart's ligament, posteriorly with the pectineal fascia, externally with the femoral vein, internally with Gimbernat's ligament. As mentioned above the possibility of the obturator artery being in relation to the neck of the sac should be borne in mind. When the hernial protrusion emerges from the saphenous opening, it is directed upward and outward by the attachment of the cribriform fascia. This causes the tumor to overlie the ligament and to occupy a position at or near the site of an incomplete inguinal hernia often rendering the diagnosis difficult. The hernial tumor is generally small, and more often contains omentum than intestine. Occasionally an ovary, the Fallopian tube, the bladder, or the appendix will be found in the sac of a femoral hernia. Strangulation occurs relatively more often than in inguinal hernia. 932 HERNIA A femoral hernia rarely gives rise to subjective symptoms until it becomes inflamed or strangulated. Exceptionally there is pain either locally or in the neighborhood of the umbilicus, and a sense of weight or dragging in the groin. In the majority of instances the presence of a small oval tumor in the groin is the first sign of the disease. In corpulent individuals this is often overlooked, and the first indication of a hernia may be the symptoms of strangulation. Diagnosis. — The presence of a rounded swelling in the groin just below Poupart's ligament and to the inner side of the femoral vessels, which is resonant on percussion, which has a distinct impulse on cough- ing, and which can be reduced with a gurgling sound, may with cer- tainty be diagnosticated femoral hernia. In the majority of cases, however, one or more of these signs are absent; thus in femoral epiplo- celes the tumor lacks resonance, in incarcerated hernia the impulse may be wanting, and in many others the tumor may rise above Pou- part's ligament and in fleshy individuals the exact position of the neck of the sac is difficult to appreciate. Femoral adenitis may be excluded by the absence of the impulse and resonance and by the fact that the glandular mass is hard, often movable, frequently inflamed, and generally associated with other enlarged glands. A small lipomatous mass is occasionally present in this region and may closely resemble a small incarcerated epiplocele. Small lipomata may occasionally be present with a femoral hernia. Psoas abscess and saphenous varix may present an impulse on cough- ing and disappear on lying down, the former generally can be felt above the iliac fossa, and is associated with Pott's disease; the latter is commonly associated with varices of the lower leg. Treatment. — Inasmuch as this variety of hernia is practically incur- able by mechanical means and the operative treatment is simple, and by it a permanent cure is nearly always obtained, operation should be advised unless contra-indicated by special considerations. Operations- for Femoral Hernia. — A large number of femoral hernias are cured by the simple operation of herniotomy for the relief of strangulation. If after the bowel is returned to the abdominal cavity the sac is separated, ligated, and cut off, the femoral canal emptied by pushing the stump of the sac well backward into the abdominal cavity, and its walls approximated by almost any kind of suture, recovery will be likely to follow. The fact apparently has been overlooked by many surgeons who have devised more or less complicated and difficult operations which have for their object obliteration of the femoral canal by transplantation of muscle or by means of some plastic opera- tion from above. These procedures are objectionable, in that they are technically difficult, often necessitate the opening of an intact inguinal canal, and are wholly unnecessary, for Coley has recently reported a series of 125 operations by the simple purse-string suture without a single relapse, more than half of his cases having already ANATOMICAL VARIETIES OF HERNIA «.):;:; passed the two-year limit. As the statistics of the Hospital for the Rupture, and Crippled show that practically 90 per cent, of relapses after operations upon all varieties of hernia occur within the first year, there seems to be no reason for employing the more complicated methods. Several methods of approximating the walls of the femoral canal are in general use. The Cushing purse-string method consists simply in the introduction of a purse-string suture of chromicized catgut around the margin of the saphenous opening. The needle is introduced through the inner portion of Poupart's ligament, then through the pectineal fascia, r Fig. 458. — Obliteration of the femoral opening by purse-string suture. (Coley.) then passed upward along the inner border of the femoral vein, and outward near the original point of entrance. When this is drawn tight and knotted the low r er portion of the canal is obliterated. (Fig. 458.) The Blake operation has for its object the obliteration of the upper portion of the canal. A mattress suture is passed from above Pou- part's ligament downward through Cooper's ligament and out of the low r er opening of the canal, then upward near the margin of the femoral vein, through the same structures and emerging again above Poupart's ligament. When this structure is tied the upper extremity of the canal is closed. The lowre margin of the canal can then be united to the pectineal fascia by a few interrupted sutures (Fig. 459). 934 HERNIA Umbilical Hernia. — Under this heading there are three varieties to consider : 1. Congenital hernia of the cord. 2. Infantile umbilical hernia. 3. Adult umbilical hernia. Congenital Hernia of the Cord is an extremely rare condition, occur- ring, according to Linfors, once in 5184 cases. To understand this variety one must recall the conditions which obtain in early embryonic life. At the eighth to tenth week of fetal life, a portion of the intestine occupies a position in the cavity of the umbilical cord, but at a later Fig. 459. — Blake's operation for femoral hernia. Mattress stitch in place and tied. Stitches to close lower opening of femoral canal inserted, but not tied: a, mattress stitch; b, round ligament; c, Poupart's ligament; d, falciform process; e, fascia of pectineus; /, femoral vein. period, it recedes to permit an agglutination of the visceral plates in this region, which normally effect a closure anteriorly and form the umbilicus. The term umbilical hernia for this variety of protrusion is really a misnomer, for at the time of its incidence no umbilicus has been formed, and it should more properly be regarded as an imperfect inclosure of the viscera by the abdominal wall. The coverings of this type of hernia consist of (1) a layer of Whar- ton's jelly, (2) a thin sac which is continuous with the peritoneum. In most cases the coverings are sufficiently transparent to permit of the contents being easily seen. ANATOMICAL VARIETIES OF HERNIA 935 In size they vary from a tiny protrusion to almost complete evisceration. Treatment. — The only cases which are amenable to treatment are those which are small enough so their contents can be reduced into the abdomen and a closure of the abdomen effected. Oldhausens method of operation is effective in small protrusions of this type. It consists of separation of the skin around the sac, the removal of Wharton jelly, reduction of the hernia en masse without opening the sac, and suture of the skin. Coley has treated two cases of small size successfully by carefully cleansing the parts, keeping them as nearly aseptic as possible, and applying pressure to the hernial tumor by means of straps of adhesive plaster en- circling the entire abdomen. Infantile Umbilical Hernia. — This variety is most common during the first year of life. It is, in reality, a simple yielding of the umbilical cicatrix, due to incomplete closure of the Fig. 460. — Umbilical hernia in a rachitic negro boy. (Ash- hurst.) Fig. 461. — Adult umbilical hernia. (Roberts.) mesoblastic layer. This type is small in size, varying from 1 to 3 c.c. in diameter. Many disappear spontaneously. They are practically always reducible and strangulation is exceedingly rare (Fig. 460). Treatment. — A simple pad or wooden disk covered with gauze placed over the protrusion and held securely by a band of adhesive plaster is all that is needed to effect a cure. Adult Umbilical Hernia. — This is the most important variety of umbilical hernia. It occurs generally in women, most frequently after several pregnancies. It may exist with or without diastases of the recti, usually there is more or less well-marked separation of the 936 HERNIA recti. The site of the protrusion is most commonly just above the umbilicus, although it may occur below it. The tumor is generally made up of a sac of peritoneum, which may or may not be covered with a fibrous tunic derived from the rectus sheath. In some cases the peritoneum is adherent to the skin and both may become so atten- uated that the peristaltic movement of the contained bowel may be distinctly seen. In many cases inflammatory adhesions are pres- ent between the bowel, the omentum and the sac, preventing reduc- tion and favoring strangulation. The hernial tumor may reach an enormous size and cause great disfigurement. The transverse colon is found in the sac more commonly than any other part of the intestine. Symptoms. — In the early stage the navel appears rounded and some- what bulging. It is larger in circumference than usual, and a distinct impulse upon coughing is felt. At first there is a slow increase in size, more rapidly later, especially if additional pregnancies follow, until finally it may assume very large proportions (Fig. 461). \Yhen at rest such a hernia appears as a flaccid abdominal appendage, as soon as the abdominal muscles are contracted, the tumor becomes erect and tense. In these cases, more or less pain may be present, especially on severe exertion. There is in addition a feeling of weakness and lack of proper support. Digestive disturbances and constipation are frequent. The size of the hernia is often an inconvenience, and the overlying skin may ulcerate on account of the poor nutrition. Pain from adhesions and attacks of local peritonitis are not uncommon. The mortality of strangulated gangrenous umbilical hernia is high, being estimated by Gibson as 67 per cent., as compared with inguinal hernia, 26 per cent., and femoral, 37 per cent. Treatment. — When the protrusion is small or of moderate size it may be treated with a pad and adhesive straps or with a truss. The use of an elastic abdominal belt gives great comfort in the more severe cases which for any reason are not suitable for operation. In the younger women where the protrusion has not assumed large proportions, operation should be performed on account of the prob- able increase in size with its attendant discomfort and diminishing chance for a complete radical cure. Obese women in middle life do not stand this operation well, as it is often difficult and prolonged. There is a mortality of 5 per cent, in irreducible cases. The simplest operation for the relief of the ordinary forms of ventral hernia, whether occurring at the umbilicus or in any other part of the abdominal wall, is to expose the sac, empty it of its contents, and excise the redundant tissue. Next expose the various layers of fascia, muscle, and aponeurosis, and unite them with three layers of sutures, the first of catgut, closing the peritoneum, the second of chromicized catgut, uniting the freshened muscular and aponeurotic layers, the third of silkworm gut, closing the cutaneous wound. ANATOMICAL VARIETIES OF HERNIA 937 If union takes place without infection, this method succeeds in the majority of instances in which the rupture is of moderate size. In large umbilical hernia and those due to an extensive diastasis of the rectus muscles, relapses are frequent and have led to the employment of other methods. Blake, Mayo and a number of other surgeons have employed suc- cessfully an overlapping of the abdominal wall. Blake's description of this method is as follows: "The method is particularly adapted to cases with diastasis of the recti and pendulous abdominal walls. It is also suitable for protru- sions elsewhere in the linea alba than at the umbilicus. It consists in the incision of a large elliptical area of skin and fat in either a vertical or a transverse direction, down to and exposing on one side at least, very completely, the sheaths of the recti. In typical operations the in- cision has included an area from 25 to 40 cm. in length and 15 to 20 cm. in breadth. The sac is partially or wholly excised and the linea alba is divided for the whole length of the skin incision. The peritoneum is separated if possible from the dorsal surface of one rectus. It is not necessarily opened except at the her- nial sac. One musculo-aponeurotic w r all is then drawn over the other. The amount of overlapping varying from 4 to 10 cm., according to the laxity of the abdominal wall. The margin of the underlapped side is sutured to the deep surface of the overlapping side by mattress sutures of chromicized gut which are tied on the superficial surface of the latter. The margin of the superficial flap is tacked, with interrupted sutures of the same material to the adjacent aponeurosis. The skin wound is then enclosed without drainage. The results of this method in the hands of Blake and others have been excellent (Fig. 462). Mayo uses a transverse incision and laps the upper margin down over the lower margin (Figs. 463 and 464). This method has the advantage of not diminishing the capacity of the abdomen and can be used when the abdominal walls are not relaxed, while the method of lapping from side to side markedly diminishes the capacity of the abdomen and may seriously incommode respiration leading to death from pneumonia due to non-aeration. The side-to-side method should therefore be reserved for cases with great diastasis and lax abdominal walls. Fig. 462. — Blake's operation for the radical cure of umbilical hernia. 938 HERNIA Ventral Hernia. — Ventral hernia is an abdominal protrusion occur- ring at some point other than the navel or groin. These hernias occur Fig. 463. — Suture of the aponeurotic and peritoneal structures, sutures placed. (Mayo.) Fig. 464. — Sutured aponeurotic and peritoneal structures. (Mayo.) more frequently from the yielding scars of operative wounds (trau- matic ventral hernia), and are therefore more commonly found in ANATOMICAL VARIETIES OF HERS I A 939 the median line, over the appendix, gall-bladder, or sigmoid, or in the lumbar regions. Diastasis of the recti from any cause above or below the umbilicus is an etiologic factor second in point of frequency. Small fatty hernias of the linea alba above the navel may, by drag- ging on the peritoneum, give rise to secondary visceral hernias in this region. The great majority of these ruptures are similar in character and general behavior to the adult umbilical hernias just described. In a small number of cases which follow abdominal wounds and which have healed by granulation, only a thin layer of skin or scar tissue covers the protruding viscera. These rarely become strangulated on account of the extensive adhesions which are generally present. Diagnosis. — This presents no difficulty in the majority of cases and can be made by inspection and palpation, the usual features of a hernia being present in all but one variety, the small, fatty hernias of the linea alba. As these consist usually in the protrusion of a small knuckle of fat from the subserous fatty tissue through a small open- ing in the linea alba, the only symptom may be a painful point in the median line and the presence of a small, tender nodule. There is little or no impulse at first and the tumor is often exceedingly small. At times there may be a well-defined sac with omental or intestinal contents. In some of this group of cases the symptoms are out of all proportion to their size and consist in some instances of pain and gastro- intestinal disturbances, diarrhea being a not infrequent symptom. Moschowitz believes that the vast majority of epigastric hernias are composed of properitoneal fat originally enclosed in the falciform ligament, traversing the hiatus in the transversalis fascia and linea alba in company with one of the perforating bloodvessels in this region. Treatment. — The treatment of ventral hernia is the same as for the umbilical variety. The epigastric variety as described by Moschowitz is treated by him as follows: "A small vertical incision is made over the centre of the so-called hernia ; the skin and subcutaneous fat are divided and retracted, thereby exposing a lump of fat. Search is now made for the bloodvessel previously mentioned. Usually it is found upon the left side of the protrusion and this vessel is caught and ligated. The fat is now teased apart in order to be absolutely certain that there is no true sac. The shreds of fat are now ligated to obviate a secondary hemorrhage. The ligatures are placed close to the bottom of the hole in the trans- versalis fascia. The stumps are now pushed back into the hole, and the latter closed with one or two stitches. Finally the skin is closed in the usual manner. Hotchkiss has reported a case of strangulated epigastric hernia but they are rare. Hernia in the linea semilunaris is extremely rare, only about 23 cases being reported in the literature, while hernia in the linea trans- versa 3 and hernia of the pelvic outlet are still more uncommon. 940 HERNIA Diaphragmatic Hernia. — A protrusion of the intestine may rarely take place through the diaphragm into the cavity of the thorax. The weak areas in the diaphragm are in front, between the chondral and ensiform fibres, and behind, near the external arcuate ligaments. Congenital malformations and traumata may also give rise to diaphragmatic openings, through which a hernia may protrude. Lumbar Hernia. — A rare form of ventral hernia in which the pro- trusion occurs in Petit's triangle, between the external oblique and the latissimus dorsi muscle, just above the iliac crest, below the twelfth rib, or through one of the vascular foramina of the lumbar aponeurosis. Obturator Hernia. — An exceedingly rare hernial protrusion through the obturator membrane, adjacent to the vessel and nerves. A tumor or fulness appears in Scarpa's triangle well to the inner side of the femoral vessels and pain is present along the course of the obturator nerve. If non-strangulated it may be approached from without along the border of the adductor longus and between it and the femoral vein. When strangulated it is best approached by the abdominal route. Hernia of the Large Intestine. — Each of the various parts of the large intestine, the cecum, ascending, transverse, descending colon and the sigmoid flexure, may participate in the formation of a hernia, and if the mechanism by which these various segments come to share in the hernial protrustion is not fully understood an operation for the radical cure of such a hernia may be beset with great difficulty for the operator, and grave danger for the patient. Parts of the large intestine, which normally have a free mesentery find their way not infrequently into the sac of a hernia and their treat- ment differs in no way from that of other portions of the intestine with a free mesentery. There is, however, a group of cases in which one has to deal with a protrusion into a hernial sac of either the descending or ascending colon, which is but partially covered with peritoneum. And the manner in which these portions of the large intestine present themselves in a hernial sac is frequently such that they cannot be reduced with the rest of the sac contents, owing to the fact that part of the sac is formed by the uncovered (by peritoneum) surface of the gut. As descriptive of the means by which this type of hernia is acquired, the French have applied the term hemic par glissement, commonly known as sliding hernia. It should be noted that this term does not apply to a hernia of those portions of the large intestine provided with a free mesentery. There are two different mechanisms by which this type of hernia may be brought about: 1. A "pulling" mechanism. 2. A "pushing" mechanism. Both of these methods have been recently described by Moschowitz, who has pointed out the successive steps by which these hernias are ANATOMICAL VARIETIES OF HERNIA 941 Fig. 465. — Sliding hernia of descending colon by "pulling" mechanism. First stage. (Moschowitz.) A, peritoneum; B, transversalis fascia; C, descending colon; D, internal inguinal ring. Fig. 466. — Sliding hernia of descending colon by "pulling" mechanism. Second stage. (Moschowitz.) A, peritoneum; B, transversalis fascia; C, descending colon; D, sac of hernia. Fig. 467. — Sliding hernia of descending colon by "pulling" mechanism. Third stage. (Moschowitz.) A, peritoneum; B, transversalis fascia; C, descending colon; D, sac of hernia. Fig. 468. — Sliding hernia of (descending colon by "pulling" mechanism. Fig. 469. — A, afferent loop; B, afferent loop; C, sac of hernia. (Moschowitz.) Fig. 470. — A, sigmoid flexure; B, descending colon; C, herniated colon. (Moschowitz.) 942 HERNIA acquired. Sliding hernias are acquired by the pulling mechanism as follows: 1. There must be a certain amount of mobilization of the ascend- ing or descending colon due to a loosening of their underlying tissues, which permits the colon to move more freely in its bed. 2. There is created an adjacent inguinal hernial sac. 3. With the increase in the size of the hernial sac traction is exerted upon the now movable segment of large intestine which is drawn toward the hernial opening. 4. With a continuation of the traction forces, it is obvious that the gut may be pulled down until it comes to form part of the posterior surface of the sac (Figs. 465, 466, and 467). Sliding hernias are acquired by the "pushing" mechanism as follows: 1. As in the previous mechanism it is necessary to have a certain amount of mobilization of the parts under consideration due to a loosen- ing of their underlying aveolar tissues which permit the colon to move more freely in its bed. 2. Abdominal pressure directed at first dorsad over the descending colon, just above its junction with the sigmoid or over the ascending colon, just above its junction with the cecum, tends to approximate the ventral and dorsal walls of the colon and if the force is then con- tinued in a direction caudad and mesad toward the internal inguinal ring, the segment of the large intestine to which the pressure has been applied tends to approach the internal ring, and if the force is continuous it is finally pushed out behind the peritoneum into the inguinal canal, giving a true sacless hernia. The treatment of these hernias begins with their recognition. Hotch- kiss has called attention to the fact that patients with a sliding hernia are exceedingly intolerant of the pressure of a truss. The hernia which is acquired by the " pulling" mechanism is apt to be large, while those which exist as a result of the "pushing" mechan- ism are usually small. Blake found that in many of these cases the gut was loosely attached to the abdominal wall, and could be pushed back en masse. Moschowitz found that in the hernias acquired by the "pushing" mechanism, it was usually possible to push them back with a little blunt dissection, not into the peritoneal cavity, but into the retro- peritoneal space and found it unnecessary to open the peritoneal cavity except to verify the correctness of the diagnosis. Both Hotchkiss and Walton have devised operations to facilitate the reduction of a sliding hernia and to effect a repair. Hotchkiss has found the following procedure successful in these cases : 1. The sac is freed from the cord to its full extent. 2. Sac is opened anteriorly and its reducible contents replaced within the abdomen and retained there with pads. 3. The incision in the sac is then prolonged upward to the internal ANATOMICAL VARIETIES OF HERNIA 943 ring and downward to the lowermost point of the sac, which will permit of easy eversion of the sac. 4. Grasping the adherent intestine and pulling it gently forward, it will be found that the peritoneum of the hernial sac will become everted in such a manner as to form a new elongated mesentery for the sigmoid with its smooth peritoneal surface turned out to form its free surface and its outer or non-peritoneal surface falling in contact. 5. Suturing the edges of this new mesentery together permits its elongation to an extent sufficient to allow the perfect reduction of previously adherent intestine into the abdominal cavity. 6. Suture the opening into the abdominal cavity with a purse-string suture introduced from within. 7. Then proceed w'ith the usual repair. Transplantation of the rectus is frequently of value in these cases. Relapses are more common than in any other form of hernia. CHAPTER XXXII. AMPUTATIONS. General Considerations. — The indications for amputation are injuries, inflammations, neoplasms, gangrene, or deformities of an extremity which either immediately menace the life of the individual, or would result, if saved, in a member which would be functionally or cosmetically inferior to a mechanical substitute. In gangrene, ampu- tation is performed to anticipate the natural separation of the dead from the living tissues. These indications vary not only with the surgical condition, but also with the constitution of the patient and the situation of the part affected. An aged or debilitated individual who would survive the removal of part of a lower extremity might fail to repair a resected joint or badly infected or lacerated wound; and an injury which in the lower extremity demands amputation, should often, in the upper, be treated conservatively. The operation is almost without exception one of last resort and should be undertaken only when failure is the only promise from any other method. The time for amputating is of especial importance in severe injuries, where there occur four distinct periods: First, immediately after the injury; second, from four to six hours afterward, when there has been partial recovery from the primary shock; third, an inter- mediary period lasting several days or weeks during which there is active inflammation; and fourth, after the acute inflammation has subsided and the dead portions sloughed away. Of these periods the second is the best if the limb is hopelessly in- jured, and the fourth if an unsuccessful attempt has been made to save it. Operation in the first stage adds to an already severe shock and in the third aids in the spreading of a very active inflammation in a weakened host. In the other conditions, being a procedure only of the last resort, the time for operation depends on the urgency of the pathological condition and the general condition of the patient. The site of amputation should be as far as possible from the trunk because of the lessened shock. It should be where the flaps will be well supplied with blood; a level often, especially in cases of gangrene, at some distance from the apparent disease, as illustrated by amputa- tion through the thigh for gangrene of a toe. This level is found by the Moschowitz test which carefully presses the blood out of the extremity by means of an Esmarch bandage and leaves a tourniquet at the base of the extremity for five minutes while the Esmarch is being removed. The tourniquet is then suddenly removed and the blood allowed to flow back into the limb. As this occurs, a pink flush will advance down the extremitv reaching; the toe in about two minutes. In vas- HEMOSTASIS 945 cular diseases, this pinkish wave will be arrested at some level, form- ing a line of demarcation below which the skin appears bloodless for several minutes. The line marks the limit of good capillary circulation and the line of amputation should be safely above it. The second consideration is to provide a serviceable stump to which an artificial limb can be readily fitted, as in the tapering portions of the thigh and leg, instead of through the knee-joint where the bulg- ing condyles not only interfere with the circulation but make an uneven surface for fitting the prothesis. For the same reason, if pos- sible, amputation of the leg should be between a level of 20 cm. from the ground and 10 cm. below the tubercle of the tibia. In the upper extremity, the longer the remaining stump the better. Preparation for Operation. — The general preparation should be for a severe surgical procedure; maintenance of strength up to the day of operation, the drinking of considerable water and a mild cathartic the day before operation. The local preparation should follow abso- lute aseptic rules where it is possible, care being taken to isolate infected areas from those which can be made sterile. This should be brought about with the least possible addition to an already severe shock, Fig. 471. — Author's solid rubber tourniquet with metal clasp. and in desperate cases, a long-drawn-out, uncertain, antiseptic prepara- tion of an already infected extremity should not be allowed to increase the danger of immediate postoperative mortality. The choice of anesthetic is that for a procedure in which the element of shock is greater than any other involving the same amount of tissue handling. It is best to give a preliminary injection of \ gr. of morphine and yws gr. of atropine one hour before operation. Com- bined general and local anesthesia is used w T here possible during the operation, the local anesthetic being directed both to the main nerve trunk and also to the subcutaneous tissues where this procedure does not delay healing. Spinal anesthesia may be indicated in the aged or those suffering from pulmonary disease. Hemostasis. — In all the major amputations it is desirable to prevent unnecessary loss of blood during the operation by the application of a tourniquet to the limb, well above the operative field, in such a position that it will compress the main arterial trunk. For this pur- pose the old-fashioned Petit's tourniquet may be employed, or simply a firm India-rubber tube drawn tightly about the limb and tied or held with forceps. The author's solid rubber tourniquet with metal clasp is perhaps the easiest to apply and to loosen (Fig. 471). 60 946 AMPUTATIONS Other methods are: digital compression of the main arterial trunks, compression of the base of a flap, immediately as it is cut, by the grasp of the hand or an elastic ligature, and by clamping and ligating the vessels as found in the dissection. Bloodless amputations can be secured by the application of the Esmarch rubber bandage from the extremity of the limb to the point of application of the tourniquet. To be effective, the limb should be blanched and remain so until the tourniquet is removed. The disad- vantages of this method are: the reactionary congestion of the limb, which occurs after the tourniquet is removed, and leads to trouble- some oozing and the necessity for many ligatures, and the permanent loss of capillary circulation in individual suffering from endarteritis. The Handling of Tissues During an Amputation. — Skin and sub- cutaneous tissues should be handled gently, because it is the most important structure for the healing of a flap, and easily injured on account of the imperfect support offered by the fat to its bloodvessels. In dissecting skin and subcutaneous tissues, the knife should be directed toward the muscles and never toward the skin, and the muscular fascia sacrificed rather than injure the subcutaneous tissue. Muscles and tendons should be sutured together over the end of the cut bone, to diminish atrophy of the stump by maintained muscular activity, to aid in the movement of the stump, and to protect the end of the stump from trauma. In planning the muscular portion of the flap allowance must be made for the difference in the contracting power of antagonistic groups, including in the longer flap the least powerful group, so that the muscular scar will be in the same position as the cutaneous, and drawn upward away from the end of the bone. Important muscular attachments such as the supinator longus in the wrist, the pronator radii teres in the forearm and the patellar tendon should remain undisturbed. Improper handling of bone and periosteum is the source of a large percentage of painful stumps because of the growth of osteophytes of various sizes and sharpness, from spicules of bone and shreds of periosteum which form bony masses gripping the sensory nerve fibres and passing directly to the overlying skin. This difficulty is avoided by simple, clean treatment of periosteum and bone, the former by a sharp knife and the latter in the same groove by a fine-toothed saw. More elaborate methods preventing these growths may be employed, as Bier's method, in which bone is made to cover the end of the cut surface of the stump. Bunge attempts to accomplish the same result by destruction of all osteogenetic tissue near the cut end of the bone : first, by an absolutely clean removal of periosteum for 3 mm. above the cut edge of the bone; and second, by the same treatment of the endosteum and marrow. The results of the latter treatment are apparently as good as those of the osteoplastic procedure, and in cases where time is valuable, is the method to be preferred. METHODS OF MAKING THE FLAPS 947 The main arterial trunks with their veins are found in their anatomical positions, and are doubly ligated after being cleanly dissected. The secondary branches are sought in the intermuscular septa, clamped and ligated as are any visible vessels in any of the muscles or subcutaneous tissues. The tourniquet is removed after such ligation, and any remaining bleeding points caught and ligated as found. If the condition of the patient warrants it, the wound is watched for about ten minutes to catch those bloodvessels which bleed during the secondary congestion following the application of an Esmarch. In a clean case this will diminish oozing and con- siderably hasten the process of repair. As far as possible the main nerve trunks are found and secured before severing the bloodvessels which accompany them. They are cleanly dissected and pulled downward from 4 to 8 cm., are anesthetized, Fig. 472. — Kinetic stump. and cut with a sharp knife, thus permitting retraction above the end of the stump or from any area which would be pressed upon by a scar. Whenever a nerve is cleanly cut there forms a so-called neurofibroma. If this structure lies loose in the soft tissues it causes no symptoms, but if caught in the bony scar tissue, causes great pain. Drainage is eliminated as far as possible, but it should be employed in infected or doubtful cases rather than risk the danger of cellulitis and osteomyelitis. Kinetic stumps are formed by making loops of skin-covered muscles or tendons to which cords may be attached and connected with various parts of an artificial limb — with a view to securing a certain amount of voluntary motion in the prosthetic apparatus (Fig. 472). Methods of Making the Flaps. — Flaps are made of skin, which should always include the subcutaneous areolar tissue ; of skin and muscle ; of 948 AMPUTATIONS 'I skin, muscle, and periosteum; or the flap may contain also a portion of adherent bone (osteoplastic amputations). Skin flaps are made by cutting from without inward with a large scalpel. The flap is generally first marked out, and should be as broad at the extremity as at the base ; otherwise the normal re- traction of the tissue will result in the formation of a conical flap which can be made to cover the muscular and bony stump only with difficulty. In raising the flap the blade of the scalpel should be directed toward the muscle, to insure freedom from injury of the subcutaneous vessels. When the flap is to be composed of skin and muscle, it can be made by transfixion, or by the method of skin dissection from without, as just described. In the method of transfixion the left hand of the operator grasps and raises the fleshy part of the limb above the bone. A long-bladed amputat- ing-knife (Fig. 473) is then passed transversely through the limb above the bone, and by a sawing motion an oval flap is made, the apex of which is directed downward. The knife is then reintroduced below the bone and a similar flap cut from the inferior aspect of the limb. These are then re- tracted, the bone sawed through, and the distal portion removed. If the flap is made by cutting from without, the skin is first incised and dissected backward for about an inch, the muscles are then divided down to the bone on either side, and separated from it by blunt dissection; or, after the skin is retracted, the muscles may be divided by transfixion, care being taken to insure the muscular part of the flap being smaller in extent than its cutaneous covering. If the flap is to contain periosteum, it should be separated from the bone, but not from the muscle, and should be of such a shape that it will fall over and cover the cut extremity of the shaft when the flaps are sutured in place. Periosteal flaps, unless made in this manner, are worse than useless, because they generally leave a portion of the bone exposed, and therefore favor necrosis. It is better to follow the advice of Bryant, and saw the bone without disturbing the periosteum. In osteoplastic amputations the object is to cover the open extremity of the shaft by a thin section cut from a neighboring bone, which retains its connection with one of the flaps. The results of this opera- Fig. 473. — Long- bladed amputating- knife. SKIN-FLAP METHOD 949 tion at the ankle and at the knee-joint have been so satisfactory that Bier and others have sought to apply it to amputations in other localities; and while it undoubtedly gives a better bearing stump when the plan can be successfully carried out, the technical difficulties in situations in which the protecting bone flap has to be sawed from the shaft of a long bone are so great that the procedure has not as yet been generally adopted. The Circular Method. — This method is chiefly applicable to the thigh and arm, but it may be used also in the leg and forearm. It is carried out in the following manner: A circular incision is made through the skin and subcutaneous tissue at a distance not less than one-fourth of the circumference of the limb, from the point of division of the bone (Bryant). This is made best by a long-bladed amputating-knife, and the integument dissected from the deep fascia and muscles and turned upward as a cuff. An assistant then draws the tissues well upward, and the surgeon makes a second circular incision around the limb, this time dividing the superficial layer of muscles. A third section is then made, after further re- traction of the soft parts by the assistant, dividing the deeper muscular layer to the bone. The soft parts are then drawn well away from the bone by a two- tailed muslin retractor, and the bone sawed through and the sharp edges rounded off by the rongeur. This leaves a funnel-shaped hood of soft tis- sue, which falls over the bone, and may Fig. 474.— Amputation through be united with a few deep catgut sutures fZh'T" * ^^ ""*"* for the skin (Fig. 474). Several modifications of this method are in use — one in which the muscles are divided by a single cut at the base of a long cutaneous cuff, another in which one or more vertical incisions are made in the skin flap with more or less rounding of the edges (Liston). Skin-flap Method. — In this method two equal or unequal flaps are made of skin and fascia. These may be an anterior and a posterior one; or two lateral flaps, each of which should be rectangular in shape, with the distal corners rounded. In cutting these flaps, one should estimate the combined length to be not less than one and a half, and often two, diameters of the limb at the point of bone section. The flaps are dissected free from the muscles and retracted, after which the muscles may be divided to the bone by a circular incision at the base of the skin flaps (Fig. 475). In case it happens that the injury or disease for which the amputation is undertaken is situated on one side only of the limb, practically the entire flap may be raised from the opposite side. Care should always be taken, however, in these cases to include the deep fascia in the flap, on account of the increased blood supply thus obtained. 950 AMPUTATIONS Skin- and Muscle-flap Method. — In this method two flaps are made, consisting of skin and muscle. These may he of equal or unequal length, and are generally made by transfixion from within outward, or by dissecting them from without inward as described above. It is a quick and easy method, and is chiefly applicable to the thigh, arm, or fleshy part of the forearm or leg. After the flaps are cut they . — — — . Fig. 475.- -Modified circular amputation: skin flaps and circular incision through muscles. (Esmarch.) should be retracted with a two- or three-tailed muslin retractor and the bones sawed, after which the muscles should be brought together with several buried sutures of heavy catgut, and the skin united in the usual manner. Lateral skin and muscle flaps, so fashioned that the incision reaches a higher point behind than in front, are advocated by Stephen Smith Fig. 476. — Amputation by Teale's method. and others on the ground of better drainage and the fact that retraction of the scar eventually brings the cicatrix behind and out of the way of pressure by an artificial limb. Teale's Method. — This method is applicable chiefly to the leg and forearm, and should consist in a long anterior flap of skin and muscle, and a short posterior flap similarly constructed. The length of the POSTOPERATIVE TREATMENT 951 anterior flap should be one-hall the circumference of the limb at the point of bone section; that of the posterior, one-quarter. Kadi flap should be rectangular, and should include all the tissues down to the hone. After section of the bones the anterior flap should be folded over the hones and stitched to the posterior flap (Fig. 476). The advantages of the method are that it affords good drainage and furnishes a serviceable stump. The principal disadvantage is that it requires a high division of the bone, and therefore involves a greater sacrifice of the limb than other methods. The Racket-shaped Method. — This method is a modification of the circular method, and consists in an oval or circular skin incision extending around the limb which is joined by a perpendicular incision extending for a variable distance upward, along the bone. It is applicable to the fingers and toes, especially when the amputation is performed at the base of the digit. A similar incision is also extensively employed at the hip- and shoulder-joints, but in these regions the flaps are made of skin and muscle. Postoperative Treatment. — Immediately after operation attempts should be made to prevent pressure of the bone end against the soft tissues of the flap. This can be accomplished by binding the limb to a splint which holds the tissues well down over the end of the bone or by making direct traction with adhesive plaster on the soft parts so that any retraction of the muscles is overcome. As soon as the wound is solid, vigorous attempts are made to increase the mobility of the stump and to diminish its abnormal sensibility. This is accomplished by massage or even rough handling, as by blows of moderate severity, by hot and cold baths, and bandaging. As soon as all sensitiveness has left the end of the bone an artificial limb should be fitted and the patient urged to make early efforts to use the extremity. Delay in this is often a serious mistake for the reason that the patients become used to crutches and are therefore unwilling to endure dis- comfort and pain which always accompany the early efforts to use an artificial leg. Conical stumps occur when flaps have been too short or where there has been growth of bone after amputation. The result is that the bone end pushes down the skin covering it into a rounded cone which often is highly sensitive and prevents the use of an artificial limb. The treatment is to reamputate with flaps cut to the proper length. Painful stumps also are caused by nerves being caught in a rigid scar, by the formation of osteophytes from ragged bone and periosteum, and from fixation <^f the scar over the bone end. Treatment is preventive by proper operative technic. Curative methods are to sever the nerve trunks at a higher level, to cleanly remove the rough ends of bone, and to interpose fat or aponeurosis between the bone end and the skin. 952 AMPUTATIONS The Use of Artificial Limbs. — With a view to determining the con- ditions which favor the successful use of an artificial limb after ampu- tation of the lower extremity, Dr. F. T. Murphy addressed a circular letter to 500 patients treated at the Massachusetts General Hospital from 1888 to 1892. He also made inquiries of eleven well-known firms manufacturing artificial limbs. From the replies he received, he concludes that a serviceable weight-bearing stump is best secured by covering the end of the bone by a layer of muscle rather than by a simple skin flap; that a periosteal covering of the end of a bone is desirable; that in leg amputations the fibula should be cut at a higher level than the tibia ; that the sharp subcutaneous tibial edge should be removed, and that every effort should be made to avoid wound infec- tion. He also found that, as a rule, all partial amputations of the foot and most amputations at the ankle were unsatisfactory, but that a tibial stump between 6 and 8 inches in length is to be preferred, as it gave to the patient an increased sense of security, far more comfort, and a greater degree of strength in the subsequent use of his artificial limb. Amputations at the knee-joint are inferior to those just above the condyles. In general it was found, as a result of these investigations, that if we aim to secure the greatest comfort in the use of an artificial extrem- ity, we should avoid joint amputations, provide adequate muscular covering for the end of the bone, and make every effort to secure primary union. The use of kinetic stumps of the upper extremity has opened a wide field for mechanical ingenuity. SPECIAL AMPUTATIONS. Amputations of the Fingers. — It should be remembered that on the dorsal aspect of the fingers the joint lies below the knuckle, which is formed by the inferior extremity of the bone alone. The distal joint lies one-twelfth of an inch below its bony prominence, the interphalan- geal joint one-sixth of an inch, and the metacarpophalangeal joint one-third of an inch below the knuckle (Jacobson). The creases on the palmar aspect practically correspond to the joint line for the distal joints; the upper one lies about three-quarters of an inch below the metacarpophalangeal joint (Fig. 477). In amputations through the phalangeal joints the method by the long palmar flap is to be preferred, for the reason that the flap is thicker, better nourished, possesses greater sensibility, and the scar is above and out of the way. The extremity of the finger should be firmly grasped and partly flexed. A long, thin-bladed knife should then incise the skin immediately over the joint line, enter the joint, and then pass beneath the head of the distal phalanx, and by one or two sawing movements cut a long palmar flap. This is turned up and united to the edge of the dorsal incision by three or four sutures of SPECIAL AMPUTATIONS 953 silk or silkworm gut. Occasionally one or two small vessels may need ligation (Fig. 47S). In amputations at the interphalangeal joint Fig. 477.— Racket-shaped incision for amputation of the finger at the metacarpo- phalangeal joint. (After Rotter.) Tiffany recommends including the tendon and its sheath in the sutures to insure good voluntary movement of the stump. Fig. 478. — Amputation of a finger by the long palmar flap. (After Esmarch.) In amputations between the joints the double skin flap may be employed, either anteroposterior or lateral. If the former is employed, the palmar should be the longer, for reasons already given. In metacar- 954 AMPUTATIONS pophalangeal amputations, the lateral flap in the index and little finger, and in the other fingers, the racket-shaped incision should he employed. Amputations at the distal joint of the thumb should be by the palmar flap; at the metacarpophalangeal or carpometacarpal joints, by the racket incision. In traumata of the hand it must be remembered that fingers or parts of fingers may often be saved even after severe lacerations and compound fractures, and that an effort should always be made to retain as much of the thumb as possible. It should also be remembered that an immovable stump of a finger is worse than useless. In many cases atypical amputations are possible, and irregular but viable strips of tissue often can be employed to cover bone and fill up gaps in the soft parts. Amputation at the Wrists. — Amputations at the wrist may be accom- plished by the double-flap method, by the long palmar flap, or by the external flap; in the latter case the flap is taken from the external surface of the thumb as high as the metacarpophalangeal joint (Dub- reuil). Of these, the palmar flap method is to be preferred. In this an incision is made from one styloid process downward on the palm of the hand to a point opposite the middle of the metacarpal bone, then transversely to the opposite side and downward to the other styloid, making a rectangular flap with rounded edges. The flap consists of skin, subcutaneous fat, and a small portion of the muscle from the thenar and hypothenar eminences. The two extremities of this incision are joined by a transverse dorsal incision. The joint is then opened from the dorsal side and the disarticulation completed by division of the ligaments and tendons, the palmar flap turned upward and united to the edge of the dorsal incision. The attachment of the supinator longus is carefully preserved. Amputation of the Forearm. — Amputation of the forearm is usually accomplished by the double-flap method. In the lower portion the flaps should be of skin from the flexor and extensor surfaces. In the upper portion the muscles may be included in the flaps. The flaps may be equal in length, but the long dorsal and short palmar method is to be recommended. The tendons or muscles are sutured over the ends of the bones, or held to the interosseous membrane. AYhen possible, the bones should be divided below the attachment of the pronator radii teres muscle, to insure pronation and supination of the stump, an important factor in contributing to the usefulness of an artificial arm and hand. Amputation at the Elbow-joint. — The circular, the double-flap, or the long anterior or posterior flap methods, may all be employed in this region. Of these, the long anterior flap, consisting of skin and muscle, is to be preferred. This is made either by transfixion or by cutting from without inward, and is joined posteriorly by a short flap of skin. When the region of the joint is exposed, it is opened from the outer side and disarticulation effected by division of the SPECIAL AMPUTATIONS 955 ligaments and tendon of the triceps muscle. The fleshy anterior flap falls over the condyles and is attached to the posterior flap by a number of cutaneous sutures. It is especially important in this amputation that the flaps be sufficiently long to avoid tension and to suture the flexor to the extensor muscles, otherwise retraction may occur and one or both condyles may protrude. Amputation of the Arm. — The conditions here are favorable to almost any method of amputation. The circular and the double-flap methods are the ones usually employed ; and have been described in the earlier part of the chapter. Here it is that kinetic stumps (see above) offer the greatest field. Amputation at the Shoulder- joint. — Hemostasis in this operation is secured best by a preliminary ligation of the axillary artery in its upper third or by digital compression of the subclavian. The use of the rubber tourniquet passed beneath the arm and drawn upward and clamped above the clavicle, and held in place by an assistant or by means of the Wyeth pins, introduced one through the anterior and one Fig. 479. — Amputation flaps: 1, circular; 2, oblique; 3, unilateral Ions flap; 4, racket; 5, bilateral with square ends; 6, bilateral with round ends as in transfixion. through the posterior fold of the axilla, each emerging one inch within the tip of the acromion, is a satisfactory method in thin subjects. Two methods are to be recommended for this amputation : the deltoid flap method and the racket incision. The deltoid method consists in a long oval skin and muscle flap, including the greater part of the deltoid. This is made by transfixion or by a cut from without inward extending from the coracoid process downward to the point of insertion of the deltoid, then backward and upward to the root of the acromion. The tissues are raised from the bone and retracted well upward. The internal rotators and then the external are severed at their insertion, the capsule is incised, the other muscular attachment severed, and the head forced upward out of the socket. The blade of the knife is then passed behind the head, and a short posterior flap made by cutting downward. The large deltoid flap is trimmed to fit the opening thus made, and after the vessels are secured is stitched to the lower margin of the wound. The racket-shaped incision is the one generally employed. In it the perpendicular portion of the incision is to be made from a 956 AMPUTATIONS point near the coracoid process (Spence) (Fig. 480), from a point between this and the acromion (Farebeuf), or from a point just beneath the acromion on the outer aspect of the arm (Larrey). In all of these the perpendicular incision is carried down- ward to a point opposite the attachment of the pectoralis major muscle to the humerus. From this point the incision is carried around the arm as in circular amputation. The vertical arm of the incision is next carried to the bone and the head exposed by lateral retraction of the two flaps thus formed. The capsule is divided, the muscular at- tachment cut, the head disarticulated, separated from the remaining soft parts, and the arm removed. Interscapuiothoracic Amputation. — In in- terscapulothoracic amputation, or removal of the entire shoulder-girdle, an incision is made from the sternoclavicular junction along the clavicle to the coracoid process; from this point the incision passes down- ward to the junction of the arm with the anterior fold of the axilla, then around, beneath the arm, to the edge of the latissimus dorsi muscle; crossing this it passes downward to the angle of the scapula, then upward across the spine of the Fig. 470. — Disarticulation at the shoulder, Spence's method. (Stimson.) Fig. 4S1. — Amputation of the arm, scapula, and part or all of the clavicle. (The dotted line represents the part of the incision which lies on the posterior aspect of the body.) (Treves.) scapula to join the incision over the clavicle about its middle (Fig. 479). The incision simply includes the skin and subcutaneous areolar tissue. The incision over the clavicle is next deepened, the SPECIAL AMPUTATIONS .957 clavicle disarticulated from the sternum and carefully raised throughout its entire length. The attachment of the pectoralis minor to the coracoid process is severed and the brachial plexus and axillary vessels exposed. The vessels are double ligated and divided, and the nerve- trunks anesthetized by novocaine (4 per cent.) and cut. The remaining portions of the incision are then deepened, the scapula fully exposed, its muscular attachments divided, and the entire upper extremity removed. The posterior scapular and suprascapular arteries should be clamped and ligated ; also a number of other smaller vessels. The two flaps, pectoro-axillary and the cervicoscapular, are then approximated and secured by silkworm-gut or button sutures. The operation is one of the severest known to surgery, and requires often the maximum of speed. It should never be undertaken unless the surgeon is equipped with the best assistance and every facility for controlling severe shock. Fig. 482. — The needles and constrictor applied: circular and longitudinal incisions for skin flap. (Wyeth.) Amputation at the Hip-joint. — What has just been said in regard to the removal of the entire upper extremity applies with equal force to amputation at the hip-joint. Formerly the operation was attended by a very high rate of mortality. Of late, however, owing to better means of controlling hemorrhage and better methods of effecting removal of the limb, the death rate has been materially lessened. Many methods of controlling hemorrhage have been employed in this operation; two only are to be recommended, that by the rubber tourniquet and Wyeth's pins, and that by compression of the common iliac through an abdominal wound, as suggested by McBurney. In the Wyeth method (Fig. 4S2) two long steel pins or skewers are thrust through the soft tissues, the first pin entering just below and a little to the inner side of the anterior superior spinous process and emerging on a level with the point of entrance, but four or five inches to the outer side of the limb. Thesecond pin is introduced through 958 AMPUTATIONS the adductor muscles, near the ramus of the pubes and to the inner side of the femoral vessels, and is made to emerge one inch in front of the tuberosity of the ischium. After protecting the points of these pins by corks, a firm piece of rubber tubing is wound several times around the limb above the pins and secured by a clamp. If an Esmarch bandage is employed previous to the application of the tourniquet, the operation will be practically bloodless, as this method controls every vessel supplying blood to the field of operation. The McBurney plan consists in preliminary laparotomy by the intermuscular method, and compression of the common iliac artery by the hand of an assistant introduced into the peritoneal cavity. The author has employed this plan, but without opening the peritoneal cavity, by stripping the peritoneum from the iliac muscle after separa- tion of the muscular fibres. The artery is as easily and quickly exposed, and, after the operation is completed, the tissues fall readily into place, and require only a few sutures and closure of the cutaneous wound. While both of these methods may be relied upon to control hemor- rhage absolutely, the author would prefer the Wyeth method in a case of shock where speed was an important factor, and the McBurney method in the case of a very fleshy individual. As the racket-shaped amputation has practically superseded all of the older methods, it alone will be described. For a description of the other methods, the reader is referred to works on operative surgery. The operation is performed in the following manner: The patient is placed on the operating-table with the hips projecting slightly over the edge. The sound leg is held out of the way by one assistant, and the diseased limb supported in the extended position by another. A circular incision is then made six inches below the tip of the greater trochanter, and a cuff of skin and subcutaneous tissue retracted. A vertical incision is then made down to the bone from the outer side of the cutaneous incision, to a point one inch above the greater trochanter. The two triangular flaps thus created are sharply retracted and the bone shelled out of its muscular bed by sharp and blunt dissection. The capsule of the joint is next opened and disarticulation effected by strong adduction and a rotary motion of the limb. As soon as the bone leaves the socket the posterior muscular attachments are severed and the limb removed. The femoral artery and vein should be ligated separately. Ligation will also be required for the profunda and descending branch of the external circumflex. Some operators prefer to place the patient on the sound side, and begin by making the vertical incision, entering the knife one inch above the trochanter, carrying the incision downward parallel with the bone for five inches, then encircling the limb. After dissecting up to the skin from the muscles for a distance of two or three inches, the muscles are divided to the bone by a circular sweep of the knife and the head disarticulated as in the other method. Rose and Carless SPECIAL AMPUTATIONS 959 advise making the perpendicular arm of the incision immediately over the femoral vessels. It is important after this operation to support the parts by a firmly applied dressing, as the cut muscular surfaces are apt to ooze consider- ably, and if the dressings are loosely applied they soon become saturated and have to be removed. If the wound is aseptic, it is desirable to allow the primary dressing to remain in place for ten days or two weeks. Amputation of the Thigh. — Amputation of the thigh, like amputa- tion of the arm, may be performed by almost any one of the methods described in the beginning of the chapter. The quickest operation is the double-flap method by transfixion, and is indicated in old and debilitated subjects, and in patients suffering from severe shock or sepsis. The osteoplastic operation gives the best results, if viewed from the standpoint of subsequent weight-bearing function, although the Teale method also gives, as a rule, an insensitive stump. Conical stump is quite common in amputations of the thigh, especially in the lower third. This is due largely to the fact that the flexor muscles retract much more than the extensors, leaving the bone more or less exposed and covered only by the skin. To remedy this, Dawbarn begins the operation by " ham-stringing," his patient, or dividing the tendinous at- tachments of the externa] and internal flexors just above the knee by a stroke of the knife. This allows retraction to take fig. 483.— Amputation by lateral place before the flaps are cut. On ac- flaps. (Roberts.) count of this tendency to muscular re- traction it is desirable in thigh amputation to allow a redundency of the extensor muscles and to suture them to the ham-strings over the divided extremity of the bone. For this purpose buried sutures of chromicized catgut should be employed. Amputation at or near the Knee-joint. — A number of excellent opera- tions have been devised for amputation at or near the knee-joint. The bilateral flap of operation of Stephen Smith is one of the most popular, and has the advantage that the scar is situated posteriorly and well out of the way of the bearing point. A curved incision is made, beginning one inch below the tubercle of the tibia and extending downward and outward over the fleshy part of the leg to a point behind on the calf opposite the tubercle; then upward in a vertical direction to the middle of the popliteal space. A similar incision is made on the inner side of the leg, but extending about one inch lower on the calf, and joining the first in front and behind. These incisions are next carried down to the bone, forming two musculocutaneous lateral flaps, which are well retracted and the line of articulation exposed. 900 AMPUTATIONS The patellar tendon is then divided, the joint opened, the leg flexed, the lateral and crucial ligaments divided, the knife carried behind the head of the tibia, and the leg severed by a downward stroke. Carden's method consists in a supracondyloid amputation with a long anterior and a short posterior flap. A curved anterior incision is made from one condyle to the other, extending downward to the tubercle of the tibia. This is dissected upward to a point above the Fig. 484. — A, Gritti's amputation at the knee; A', lines of division of the bones; B, amputation of the thigh, long anterior flap; B', division of the bone; C, amputation at the lower third of the thigh; C", division of the bone; D, disarticulation at the hip- joint. (Stimson.) patella. A posterior incision is then made connecting the two extrem- ities of the anterior cut, and is carried through all the soft parts to the bone. The muscular structures on the anterior aspect of the thigh are then freely incised and the bone sawed just above the condyles. The Gritti or Stokes Method (Fig. 484). — This is an osteoplastic amputa- tion. A curved anterior incision is made, as in the Garden operation, extending from one condyle to the other through the patellar ligament. SPECIAL AMPUTATIONS 961 The flap is retracted strongly upward, the leg acutely flexed, and the joint freely opened. The blade of the knife is then passed behind the head of the tibia and a short posterior flap cut from within outward. The articular surfaces of the femur and patella are then sawed off, exposing bone tissue. In the Gritti operation the femur is sawed through the condyles; in the Stokes operation, just behind. The latter is to be preferred, as its cut surface more accurately fits the patella. The anterior flap with the adherent patella is then allowed to fall over the cut surface of the femur and is sutured to the edge of the posterior incision. If any tendency to displacement of the opposed bony surfaces is present, they are held by one or more chromicized catgut sutures passed through holes drilled in the two bones. It is desirable in this operation to remove as much of the synovial membrane as possible, and to touch the remaining portions with pure carbolic acid, to promote adhesion and to prevent accumulation of synovia. Amputation of the Leg. — In the upper half of the leg the circular or the transfixion method may be employed. In the lower portion Teale's method (Fig. 476) or the long posterior flap operation is to be preferred, depending on the condition of the soft parts. Bryant advises in the lower third a circular amputation with a periosteal flap cut from the subcutaneous surface of the tibia and retaining its connection with the skin. After division of the bones the periosteal flap is placed over the cut surface of the tibia and the cutaneous edges united obliquely, so that the scar lies between the bones. In all amputations of the leg the fibula should be sawed about one- half inch above the tibia. Bull advises an oblique section of the crest of the tibia before closure of the wound. Amputation at or near the Ankle-joint. — The Syme Amputation. — Enter the knife at the tip of the external malleolus and carry the incision, extending to the bone, directly downward and then across the sole to a point half an inch below the tip of the internal malleolus. Dissect this heel flap backward from the os calcis until the tendo Achillis is reached. Then connect the two extremities of the plantar incision by an oval anterior incision approximated at right angles to the plantar, dividing all the soft parts to the bone. The joint is next opened from in front, the lateral ligaments divided, and the foot removed. The flaps should then be retracted upward, and the malleoli, or even the entire articular surface of the bones, removed. After traction on and division of the exposed tendons, and ligature of the vessels, the flaps are approximated and united. Drainage may be secured from the angles of the wound or by means of a separate opening at the bottom of the cup-shaped dead space in the heel flap. The Pirogoff Operation (Fig. 485). — The incisions for this operation are practically the same as in Syme's, the plantar cut being made about half an inch further forward. The heel flap is dissected from the os calcis only about one inch from the incision, The joint is then 61 902 AMPUTATIONS opened, the lower ends of the tibia and fibula removed, and the cal- caneum sawed obliquely through in the line of the plantar incision, removing its articular surface and leaving the posterior portion attached to the heel flap. When the heel flap is raised up, the cut surface of the Fig. 485. -Pirogoff's amputation: A, cutaneous incision (outer side); B, line of section of the bones. (Stimson.) calcaneum is brought in contact with the cut surface of the tibia and held in that position by the cutaneous sutures. This gives an excellent stump with but little shortening of the limb. The Roux Operation (Fig. 486). — Enter the knife one-half inch above the insertion of the tendo Achillis, carry the incision by a downward curve beneath the external malleolus over the dorsum of the tarsus to Fig. 486. — Amputation through the ankle-joint by large internal lateral flap. (Roux.) a point in the middle of the instep one inch in front of the articular edge of the tibia, then downward and inward to the middle of the sole, and backward and upward to the point of the beginning. Carry the incision to the bone throughout and raise the plantar flap. Open SPECIAL AMPUTATIONS 963 the joint from the outside, remove the foot, saw off the malleoli, and unite the flap with silkworm gut. Midtarsal amputations are not to be recommended. The Lisfranc Amputation. — Disarticulation of the tarsometatarsal joint. — Extend the foot and make an anterior curved incision from a point just in front of the base of the first to the base of the fifth metatarsal bone. Divide all the tissues down to the bone and separate the metatarsal bones from the cuboid and the cuneiform bones, remem- bering that the middle cuneiform bone is shorter than its fellows, and that the second metatarsal bone projects upward into this mortice. When the joint is freely opened, pass the blade of the knife behind the metatarsal bones and cut a thick U-shaped flap from the plantar surface of the foot to the base of the toes. Next remove all fragments of tendons, ligate the bleeding vessels, and turn the plantar flap upward and attach it to the dorsal by a sufficient number of silkworm-gut sutures. Heys operation differs from this in that he removes the lower projecting extremity of the inner cuneiform bone. In Skey's operation the base of the second metatarsal bone is sawed off even with the internal cuneiform. Amputation at the Metatarsophalangeal Joints. — Amputation at the metatarsophalangeal joints, or disarticulation of all the toes, is an operation rarely called for except for gangrene from frost-bite or Ray- naud's disease. Both dorsal and plantar flaps should be cut to the web of the toes, and an attempt made to bring the scar as near the dorsal aspect of the stump as possible. Amputation of the Toes. — Amputation of the toes are carried out by the same methods as in amputation of the fingers. In the metatar- sophalangeal disarticulation the bilateral flap or racket method is usually employed. In disarticulation of the terminal phalanges the long plantar-flap method is to be preferred. CHAPTER XXXIII. DEFORMITIES AND THEIR CORRECTION. Scoliosis, or Rotary Lateral Curvature of the Spine. — Scoliosis is usually an acquired, though occasionally a congenital deformity of the spine, characterized by a more or less well-marked lateral bending and twisting of the spinal column, and consequent asymmetry in the appearance of the thorax, abdomen, and extremities. The disease develops in the majority of instances before the tenth year, and is far more common in girls than in boys. A slight compensatory curve in the spine will result from a faulty position of the head, shoulder, or body, habitually assumed in standing, walking, or sitting; also from an inequality in the length of the legs, or from an asymmetric development of the pelvis or muscles. Broadly, however, etiological factors may be classified as primary and secondary. Under primary causes come congenital deformity, rickets, and occupa- tions leading to an habitual faulty position. Secondary causes are the previous existence of paralysis or deformities of the extremities, diseases of the various systems of the thoracic organs, or defects in sight or hearing. These secondary causes give rise to compensatory curvatures of the spine, which naturally increase with age and growth, and correspondingly are corrected with increasing difficulty. At length changes occur in the vertebra 3 , as atrophy of the vertebral bodies on the concave side and thickening on the convex aspect, distortion of the sagittal plane, and general asymmetry of the individual vertebrae, resulting in permanent deformity. As the spine is bent, rotation on its vertical axis occurs. In this rotation the bodies of the vertebrae are directed toward the convexity of the lateral curve, which causes a bulging of the costal arches poste- riorly on that side, with a compensatory retraction of the thorax on the opposite side. This distortion of the thorax causes'pressure on its contained viscera, occasionally resulting in pathologic changes. Atrophy and lengthening of the ligaments and muscles are observed on the convex side of the curve, with shortening of these structures on the concave side. Symptoms. — The symptoms of scoliosis are, in the earlier stages, simply the occurrence of "round shoulders" in a child, a lowering of one shoulder, or a slight departure from the normal erect position of the body in standing or walking. Occasionally, however, symptoms of weakness and awkwardness may precede the deformity, or at least may cause its observation, together with general indifference, laziness, and lack of co-ordination and muscular control. There is also a'change of asymmetry in the triangles formed by the dependent armsjmd the SPONDYLOLISTHESIS 905 lateral aspects of the trunk. This easily may be corrected by voluntary effort on the part of the patient, but the corrected posture is tiresome and the child soon assumes the faulty one. As the disease progresses the postural deformity becomes more marked, and an abnormal prominence of the ribs may be noticed on one side, especially when the child bends forward and the thorax is examined from behind. Exces- sive prominence of one hip, the fact that the nipples are not in the same horizontal plane, or that one scapula is more prominent than the other, should also be regarded as signs of scoliosis. On examining the patient from behind and applying friction to the spine, the extent of curve can be appreciated by observing the red line of the spinous processes. Fig. 487 shows an example of a well- marked type of the disease. Treatment. — In the early stages of the disease the treatment should consist in removing the cause of the faulty atti- tude, and in the use of light gymnas- tic exercises to develop the weakened muscles which are employed to hold the body in a correct posture. For this pur- pose the ordinary setting-up drill of military tactics is the one to be recom- mended. If the disease is more ad- vanced, heavy gymnastics to over- develop the muscles, are often of advantage. Supporting corsets of plas- ter of Paris, paper, or leather, are often employed to hold the body in a normal position if the muscles are easily tired and the child constantly assumes faulty attitudes which tend to exaggerate the deformity. In the severer cases in which there is fixed bony deformity, forcible cor- rection by means of traction straps, and the application of a plaster jacket, while the patient is held in the corrected position, constitute the best treatment. A few days or weeks later another jacket is applied in the same manner, and when the deformity is finally overcome a removable leather or celluloid jacket should be worn, and heavy gymnastics practised daily. Metal braces are occasionally useful for this condition. More favorable results have lately been achieved by the Abbott jacket, or by the modification of Dr. Abbott's principle, the Kleinberg brace. For a description of these the reader is referred to a work on orthopedic surgery. The prognosis in advanced cases is not favorable. Spondylolisthesis. — Spondylolisthesis is an extremely rare deformity, due to a subluxation forward of one of the lower lumbar vertebrae or a Fig. 487. — Severe lateral curva- ture (back view). (Lovett.) 966 DEFORMITIES AND THEIR CORRECTION projection forward of the upper sacral segment. This may occur as a result of some congenital defect or an abnormal position of the spine during intra-uterine life of the fetus; or it may develop during childhood or adult life from trauma, overstrain, or disease of the lumbo- sacral joint. As a result of this displacement there is an abnormal increase in the lumbar curve of the spine (excessive lordosis), a diminu- tion in the normal obliquity of the pelvis, causing tension on the anterior ligaments of the hip and a consequent flexed position of the thighs (Bradford and Lovett). The typical deformity is usually seen in women, and first therein diagnosed because of its influences on parturition. Symptoms. — The symptoms of the disease are a faulty position when standing and a peculiar waddling, duck-like gait, sometimes almost ataxic in character. Pain in the lumbar region radiating down the limbs is common. When standing erect, the body is bent forward, there is a marked prominence of both hips, and the thorax seems abnormally near the pubic crest. Complete extension of the thighs is impossible (Fig. 488). Vaginal or rectal examina- tion reveals the presence of a prom- inent sacral or sacrolumbar bony projection. The disease resembles closely double congenital dislocation of the hip, but can be distinguished from that malady by the absence of vertical mobility of the femur, and the fact that the trochanters are not above Nekton's line. Treatment in the cases in which there is pain, or in which the de- formity is the result of injury should be by means of a spinal brace or strong corset. In young sub- jects exercises to prevent limitation of flexion, and the avoidance of postures favoring deformity are indicated. Congenital Dislocation of the Hip. — Congenital dislocation of the hip is a comparatively rare malformation, but the most common and most important of the congenital displacements. Over 80 per cent, of cases occur in girls. In almost one-third of the cases the disease is double. In this condition the head of the femur occupies a position above and behind or in front of the acetabulum. The capsule of the joint is still adherent to the rim of the acetabulum, but is markedly thick- ened and elongated, so that the lower portion adherent to the acetabular Fig. 488. — Spondylolisthesis. \ '■/■'/■:. \T VENT OF CONGENITAL DISLOCATION OF THE III/' 967 rim is contracted and the upper and inner portion is firmly attached to the new socket. The head of the bone in these cases is often under- developed, and the acetabulum shallow and filled with fibrous tissue and fat. Diagnosis. — The diagnosis of congenital dislocation is often difficult in young and fat children. As a rule, these children walk late, and the gait is a peculiar waddling one, accompanied by an exaggerated swaying of the body. The hips are exceedingly prominent and the perineal space widened. The trochanters are above Nekton's line, and the head of the bone occasionally may be felt on the dorsum of the ilium, though of more importance is the fact that it cannot be felt in its normal position. There is marked com- pensatory lordosis, and the femur can be moved upward and down- ward for an inch or more (Fig. 489). There is no history of in- jury. Treatment. — Two methods of treatment are in use for the cor- rection of this deformity: reduc- tion by manipulation or the blood- less operation of Lorenz, and the method by open operation recom- mended by Hoffa. The former is to be recommended in children between the ages of two and eight, although it is occasionally success- ful between ten and thirteen years of age; the latter operation after the age of ten and in cases in which the method by manipula- tion has failed or where relapses have occurred. Lorenz s method consists in overstretching and rupturing the con- tracted and shortened muscles by traction, extreme abduction, flexion, and extension, and subsequently effecting reduction by manipulation, as in acquired dislocations. The limb is then placed in a position of extreme abduction and held by a firm plaster spica, which should be left in place for from six to eight months. After its removal the leg gradually should be brought into normal position. Hoffa s method consists in making an incision from the anterior superior spinous process downward and backward, passing behind Fig. 489. — Lordosis and prominence of trochanter in congenital dislocation of hip. (J. S. Stone.) •MIS DEFORMITIES AND THEIR CORRECTION the greater trochanter. This incision is deepened until the capsule of the joint is exposed. The soft parts are then thoroughly retracted, the capsule opened, the acetabulum examined and its contents removed, the head of the bone dislocated from its false position and placed in the socket. The capsule is then sutured, the wound closed with drainage, and the thigh fixed in a position of flexion and abduction by a plaster cast. Osteotomy may be necessary later to bring the limb into proper position. Congenital dislocations of the knee, patella, ankle, shoulder, elbow, and wrist are extremely rare. For a description of them the reader is referred to works ou orthopedic surgery. Fig. 490. — Cross-section of the pelvis and the deformed femur. A scheme to show the effect of the deformity in limiting abduction of the limb. The dotted outline shows the normal relation. (Whitman.) Coxa Vara. — Under normal conditions in childhood the angle of junction of the axis of the neck of the femur with that of the shaft is an obtuse one. As a result of complete or incomplete fracture of the neck of the femur in childhood, or as a result of other abnormal con- ditions, the exact nature of which is not well understood, a bending of the neck occurs so that its junction with the shaft approaches a right, or even an acute, angle. This results in an elevation of the trochanter which may be well above Nelaton's line, an adduction and evcrsion of the limb, and an inability to abduct the thigh beyond a certain point (Fig. 490). DIAGNOSIS OF KNOCK-KNEE 000 In double coxa vara the abduction may be so marked that the legs are habitually crossed, and locomotion becomes greatly embarrassed or even impossible. Symptoms. — The symptoms of this condition are at first irritation about the hip-joint, with unusual fatigue on walking, slight limping, a peculiar swaying gait, and, in double coxa vara, a well-marked lordosis on standing. The limb is shortened, the foot everted, and the trochanter is felt higher than normal. Extreme abduction is lim- ited by contact of the tip of the trochanter against the rim of the acetabulum. The condition is occasionally associated with rickets, and scoliosis frequently results when the disease is unilateral. Treatment. — The treatment, as advised by Whitman, should consist in subtrochanteric osteotomy, correction of the deformity by extreme abduction, and fixation of the limb in this position by a plaster cast until the bone is firmly united. In cases of traumatic coxa vara, where the patient is seen before solid union has taken place, or in cases due to rickets, where the bone is still soft and yielding, the deformity sometimes can be reduced by manipulation (extreme abduction), after which it should be held in the corrected position by plaster, as after operation. Coxa Valga. — A rare condition, the reverse of coxa vara, in which the angle made by the shaft and neck is more obtuse than normal. The diagnosis is rarely made except by the z-rays. A few cases have been reported as being relieved by an osteotomy of the neck and correction of the deformity by elevating the limb. Knock-knee. — Knock-knee is an internal angular curvature of the lower extremity, the apex of the angle being at the knee-joint. This occurs chiefly in infancy and early youth. In the infantile variety it is generally due to rickets, and the deformity may occur before attempts at walking have been made. Generally, however, the deformity appears with the first attempts at walking, and shows a strong tendency to progress as the use of the limbs is increased. In the adolescent type the disease appears between the ages of ten and eighteen, and is commonly associated with occupations requiring constant standing. The chief pathologic factors of the deformity are increased length of the internal condyle of the femur and atrophy of the external, with or without changes in the head of the tibia. With this there may be a curve in the shaft of the femur and relaxation of the internal lateral ligament of the joint. Diagnosis. — The diagnosis is easily made by inspection (Fig. 491). In double knock-knee the gait is peculiar, owing to the necessity of separat- ing the thighs to allow the advancing knee to pass its fellow in walking. If the legs are flexed on the thighs, the deformity partly disappears; if the thighs are also flexed, the deformity may be completely absent. In the extended position the examination should always be made with the condyles flat on the examining table. 970 DEFORMITIES AND THEIR CORRECTION With well-marked knock-knee there are often an external rotation of the tibia and flat-foot. Treatment. — In the earliest stage, up to four years of age, the deform- ity may be corrected by massage, general tonic measures, and proper -^ Fig. 491. — Knock-knee. (Whitman.) braces applied to the legs. In the severer forms, and after four years of age, operative treatment only is to be recommended; and of the various methods, supracondyloid osteotomy gives the best results. It is performed as follows: Fig. 492. — Osteotome. The knee should be flexed and the limb placed on a sand-bag with the inner surface uppermost. A small vertical incision is made one inch above the adductor tubercle and an osteotome (Fig. 492) introduced, turned, and its cutting edge applied transversely to the BOW-LEGS 971 long axis of the hone. With a mallet the osteotome is driven three- quarters through the bone, care being taken to cut through cortex both above and below. The leg is next extended, the limb grasped above and below the joint, and the femur fractured. The deformity is then overcorrected sufficiently to simulate well-marked bow-leg and the limb placed in a plaster cast, after suture of the wound, and the application of a pad of sterile gauze. The plaster bandage is worn for from four to six weeks, and should then be supplemented in young subjects by a brace, which should be worn for several months, because of the laxity of the ligaments of the knee-joint. Massage and exercise should also be employed. Fig. 493.— Bow-legs. (Lovett.) Bow-legs. — This deformity, which consists in an outward curvature of the limb, is, like knock-knee, commonest in children. It rarely occurs before early attempts at walking have been made or after the fourth year, and is almost always due to rickets. It is more common than knock-knee, the proportion being about 8 to 5. In this condition the deformity is caused by a bending of the femur or tibia, or of both combined, from inability of the softened bones to support the weight of the body. In the majority of cases there is a gradual outward bowing of both the femur and tibia. In other cases the bending is limited to the lower third of the tibia. In some instances there is, in addition to the outward curve, an anteroposterior curve of one or both bones, the convexity being forward. Flat-foot is generally present (Fig. 491) in rachitic cases. In other cases flat-foot as an accompanying 972 DEFORMITIES AND THEIR CORRECTION deformity is rare, as the relation of the bones is such that the body weight falls on the outer rather than on the inner side of the foot. It occasionally happens that bow-leg and knock-knee are seen in the same individual (Fig. 494). Diagnosis. — The diagnosis is easily made. The child stands with the feet apart; the knees are widely separated and the feet everted. Fig. 494. — Knock-knee and bow-leg. (Whitman.) On walking, the body sways from side to side, and the child instinctively attempts to invert the feet to help maintain his equilibrium. To determine whether the femur is involved, the legs are crossed until the knees are in contact; if an oval separation of the thighs still exists, there is curvature of the femur. Spontaneous cure of the deformity without treatment undoubtedly occurs in certain cases, the number of such cases being greater than in knock-knee. CLUB-FOOT 973 Treatment. — As soon as a tendency to bow-legs is noticed, walking should be discouraged and a vigorous tonic and antirhaehitic treatment inaugurated. Steel braces and other forms of supporting apparatus may be useful, up to four years of age, to prevent increase in the deformity. Gradual correction by bending the limbs and maintaining the position by plaster casts will bring about a cure in cases in which the bones are still soft. After the bones have become hardened, how- ever, operative treatment is indicated. Osteotomy of the tibia or femur, or of both combined, at the point or points of greatest curvature, with immediate overcorrection of the deformity and the application of a plaster cast to the entire limb, including the pelvis, is the method of choice. Club-foot. — The term club-foot is generally employed to indicate any^deformity, either congenital or acquired, which interferes with the normal plantigrade attitude of the foot in walking. Used in this sense, the term is synonymous with the word talipes, which literally signifies a walking upon the ankle or tarsus, a condition often present in the severer grades of club-foot. Four regular varieties of club-foot are described: talipes varus, in which the foot is turned inward; talipes valgus, in which the foot is turned outward; talipes equinus, in which the foot is in a position of extreme plantar flexion; and talipes calcaneus, in which the foot is in a position of extreme dorsal flexion. Clinically, these forms are often associated, as in talipes equinovarus and talipes calcaneovalgus. The causes of congenital club-foot are not well understood, but most authorities agree that the deformity is 'probably due to some restriction to the free motions of the foot and ankle during intra-uterine life and to arrested development. The causes of acquired club-foot are, in the order of their frequency: infantile paralysis, which allows the foot to be drawn out of place by the action of certain unopposed muscles; the various forms of spastic paralysis, which cause contraction of certain muscles or groups of muscles; the effects of scars from burns, lacerations, and deep-seated suppuration; and the results of certain injuries and diseases of the bone and joints. Talipes Equinovarus, or Congenital Club-foot. — This is by far the most frequent form of the affection, it being the deformity present in 77 per cent, of the congenital cases. It is often associated with spina bifida and other congenital malformations. The deformity consists in an inward dislocation of the anterior part of the foot at the mediotarsal articulation. With this there is also contraction of the plantar fascia, the Achilles tendon, and the tendons of the tibialis anticus and posticus muscles (Fig. 495). In the severest cases the bones are deformed and their normal relations changed. In the acquired form of talipes equinovarus the disease is generally due to anterior poliomyelitis, and the deformity closely resembles the congenital form. 974 DEFORMITIES AND THEIR CORRECTION Talipes valgus is usually an acquired affection, and will be con- sidered in the section devoted to Flat-foot. Talipes equinus is occasionally seen as a congenital affection, but is much more common in the acquired form. In these cases it is due to paralysis of the anterior muscles of the leg, to contraction of the soleus and gastrocnemius, to a falling downward of the foot during long periods of recumbency, and as a compensatory length- ening of the limb after fracture and other conditions associated with shortening. The deformity consists in an extreme position of plantar flexion. The heel is elevated and the patient walks upon the distal extremities of the metatarsal bones (Fig. 496), or, in more marked Fig. 495. — Congenital talipes equinovarus (club-foot). (Whitman.) cases, the toes may be flexed and their dorsal surfaces may be applied to the ground. Occasionally the deformity is associated with valgus or varus. Talipes calcaneus is much rarer than the preceding. It is more common, however, as an acquired than as a congenital defect. It is frequently associated with a certain amount of inversion or eversion of the foot. In this form the heel is depressed and the anterior portion of the foot elevated. The patient walks upon the heel. Pes cavus is a term applied to an acute arching of the sole of the foot. This is often associated with the different varieties of talipes, and is the opposite of pes planus, or flat-foot. CLUB-FOOT 975 Treatment. — The treatment of congenital club-foot should be inaugurated at the earliest possible moment. During the first few weeks after birth the nurse or mother should be taught to correct the deformity several times each day by gently pressing the foot into a normal position with the hands. At a later period the surgeon should attempt to overcorrect the deformity by manipulation, and to maintain the position thus obtained by the application of adhesive straps or a plaster-of-Paris cast in which a flat, wooden sole has been imbedded. Persistent efforts by this method will result in a cure in the majority of cases. If, however, the condition has been neglected until the soft tissues are less yielding, and the bones are firmer and deformed by walking, which always tends to increase the deformity, operative methods must be employed. These should be tried in the following order: First, forcible correction of the deform- ity, under general anesthesia, by manipulation or by the use of var- ious forms of apparatus, and the subsequent application of a plaster cast. Second, division of the tendo Achillis, with subsequent correction of the deformity by manipulation. Third, division of the tendons of the tibialis anticus or posticus. Fourth, incision of all the resisting struct- ures on the inner side of the foot, down to the bone, the incision be- ginning just in front of and a little below the internal malleolus, and extending to the outer side of the neck of the astragalus (Phelps). Fifth, the removal of a wedge- shaped piece of bone from the outer side of the os calcis or astragalus, or removal of the entire astragalus. In the early non-operative treatment of club-foot, and after any of the above-mentioned operative procedures, the greatest care should be exercised to prevent a relapse. For this purpose the various kinds of club-foot shoes or braces will be found of value. A description of these may be found in any work on orthopedic surgery. For the treatment of talipes equinus, division of the tendo Achillis is all that is required in the majority of cases. In severe cases of paralytic origin, whether of equinus or calcaneus, astragal ectomy with backward displacement of the foot upon the malleoli, often combined with tendon transplantations, has given by far the most satisfactory results. The early employment of this Fig. 490. — Talipes equinus. (Lovett.) 970 DEFORMITIES AND THEIR CORRECTION operation will prevent the atrophy and distortion of the foot that is usually seen in late neglected cases. Flat-foot. — This condition, better spoken of as "weak-foot," is a disability whose characteristic in all stages is a persistence of the passive attitude of abduction, in place of normal alternation of posture. This disuse of the functional capacity of the foot is followed by restric- tion of motion, particularly in the range of adduction and plantar flexion, which restriction gradually develops into a deformity. This deformity is simply an exaggeration of the normal posture assumed when the foot supports weight. An analysis of the deformity is as follows: (1) The leg is displaced inward, the weight of the body therefore falling on the inner side of the foot. (2) The leg is rotated so that a perpendicular line dropped from the crest of the tibia, instead of falling through the second toe falls inside the great toe, or even over the centre of the internal border of the foot. The leg has thus a tendency to slip downward and inward from off the foot, the astraga- lus slipping downward and inward from off the os calcis until its movement is checked by the calcaneonavicular, deltoid, and inter- osseous ligaments. As this tendency progresses to deformity the supporting ligaments become stretched and the muscles weakened, so that an actual subluxation of the astragalus is present. Thus the picture of the advanced deformity, the real "flat-foot," is as follows: The arched part, or waist of the foot appears much broader than normal, the heel projects, the external malleolus is much less promi- nent than normal; the internal malleolus is much more so, and with the astragalus overhangs the bearing surface of the sole. The condition is frequently encountered in childhood, but rarely then gives rise to symptoms, on account of the relative insignificance of the child's weight, the symptom usually developing later under the greater strain of increased weight and regular occupation. The disability is most commonly encountered between the ages of ten and thirty, is slightly more common in males than females, and is favored by occupations that induce a persistence of the passive atti- tude, such as barkeepers, waiters, cooks, and shop assistants. Symptoms. — The symptoms begin as a feeling of weakness, the patient gradually recognizing a persistent sensation of discomfort, tire, and strain about the inner side of the foot and ankle ; sometimes after long standing a dull ache in the calf of the leg, or pain in the knee, hip, or lumbar region. After a time he realizes that he is accommodat- ing his habits to his feet — that he rides where he once walked, sits where he once stood, that his feet have lost their spring, that his gait is slouchy, that he cannot get comfortable shoes; and that he finally speaks of himself as having a weak ankle, gout, or rheumatism. As a rule, actual pain is felt only when the foot is in use, and it must be remembered that pain is a symptom of strain, injury, and progressive deformity. Thus it may be encountered before deformity can be demonstrated, and be absent after deformity is established. FLAT-FOOT 977 Diagnosis. — Diagnosis should be made on the basis of an orderly examination. (1 ) Examine the attitudes of standing and walking, look for the heel walk, the slouchy gait, and the exaggerated turning out of the feet. (2) The distribution of weight and strain is often shown by the wearing off of the inner border of the shoe, and the bulging of the inner side of the sole. The line dropped from the erest of the tibia, as before mentioned, falls inside the great toe. (3) The slight con- cavity that should be present between the toes and heels when the feet are placed in apposition is replaced by a convexity when weight is borne. (4) Restriction of the normal range of active and passive motion, particularly that of adduction or inversion of the foot. (5) Tracing of the bearing surface of the foot, and the comparison of its size and shape with that of the normal. This test is of the least value. Fig. 497. — Flat-foot of extreme grade. (Lovett.) Treatment. — Treatment aims at the restoration of function, which must be accomplished by the correct application of the patient's muscular power. All bars to that application, therefore, such as deformity, pain, adhesions, or contractions, must previously be removed. In the ordinary cases the routine treatment is as follows: (1) Providing the patient with a proper shoe, and, as a rule, raising the inner border of the heel and sole a quarter of an inch, enough to throw the weight on the outer border of the foot. (2) Calling the patient's attention to the improper attitudes that he has been assum- ing, showing him that he must at all times try to throw his weight on the outer border of his feet, that he must place his feet parallel to one another in walking, try to press down the sole of his shoe with his toes, and to employ the lift of the calf muscle by fully extending his leg and raising his body on his foot. (3) Giving the patient exercises 61 978 DEFORMITIES AND THEIR CORRECTION devoted to strengthening the museles of adduction and plantar flexion — thus continually adducting and inverting the foot at every oppor- tunity. Also rising on tiptoe and sinking slowly, throwing the weight on the outer borders of the feet should be done from twenty to one hundred times a day. He should, however, be impressed with the fact that the best of all exercises is the proper walk. (4) If the patient is not able voluntarily to prevent deformity, a brace will be necessary to hold the foot in proper position and prevent discomfort. This brace Fig. 498. — The outlines of Dr. Whitman's brace: A, the astragalonavicalur articu- lation, the highest part of the arch. differs from the useless supports, plates, pads, springs, etc., that are commonly applied, in that those who apply such treatment regard the deformity as a direct breaking down of the arch. As has been shown, this is not the case, the deformity — except in rare cases of true "pes planus," where the foot is flat without pain and without ab- duction — being a compound one of lateral deviation and sinking. Therefore the brace required to correct it is one that will prevent both factors in its production, and hold the foot laterally as well as support the arch, while it does not interfere with the normal move- Fig. 499. — Shows the under surface of the brace and the outer flange: B, the calcaneo- cuboid articulation; C, the extremity of the fifth metatarsal bone. ments of the foot, thereby allowing the increase of muscular strength and ability on which cure depends. It is impossible in this space fully to describe the methods of making and fitting the brace. The accompanying illustration will give some idea of its shape and the method by which it is fitted. It should be emphasized, however, that in taking the plaster cast of the foot on which the brace is fitted that the foot should be in the corrected posi- tion (adduction) and that a mere impression of the sole as the patient HALLUX VALGUS 979 stands is useless. It should also he understood that it is useless to apply a hrace to a rigid, deformed, or painful foot. Such feet must first he treated by stretching and adhesive-plaster strapping until they are practically painless, until deformity is overcome and active motion is possible, when the brace may then be applied. Some feet are so rigid and so painful that they can only be stretched under an anesthetic. They should then be placed in plaster of Paris in the over- corrected position, and allowed to remain there for about a month, during which time the patient is encouraged to walk about. The cast is then removed, and the patient treated as the mobility of his foot indicates. In conclusion two points should again be emphasized: (1) that weak-foot in all its grades is characterized by the persistent attitude of abduction, which attitude must be corrected if cure is to be accomplished; (2) that the depth of the arch is of minor importance in comparison with the other symptoms and physical signs. Hallux Valgus.— This condition, which consists, in an outward devia- tion of the great toe, is fairly common in individuals past middle life. It may be congenital or even hereditary, but in the great majority of instances it is caused by an ill-fitting shoe which either compresses the toes, or, by being too short, forces the prominent great toe to one side. In extreme cases the toe may lie transversely across the other toes, in contact with their dorsal surfaces. This produces a sub- luxation of the metatarsophalangeal joint, the head of the metatarsal bone making a projection on the inner side of the foot, and by friction of the shoe may become enlarged by the growth of an exostosis. A bursa forms between the head of the bone and the soft parts, which may become inflamed, forming a bunion. This may suppurate, and give rise to a more or less extensive cellulitis of the foot, a suppurative arthritis, and occasionally osteomyelitis of the metatarsal bone. In the late suppurative condition just described, the treatment should consist in incision and drainage, with excision of the joint and removal of the dead bone if necessary. The early or minor grades of deformity may be corrected by means of a proper shoe, by splinting the toe at night, and by the use of the Holden toe-post. This is a thin piece of metal fixed upright in an inner sole, so that it separates the first and second toes, and holds the former in an improved position. In this, of course, a special shoe and a digitated stocking are necessary. When the deformity is more marked operation will be necessary. The inner aspect of the metatarsophalangeal joint is approached by a longitu- dinal or U-shaped incision. The bursa is dissected free from the bone, from below upward, leaving the upper margin attached to the phalanx. The joint is next opened and the deformity removed by excision of the exostoses or by complete resection. The free bursa is then inter- posed between the ends of the bones and held in place by a catgut suture. The external wound is next closed, the position of the toe 980 DEFORMITIES AND THEIR CORRECTION overcorrected by means of a triangular pad placed between it and the second toe, and a sterile dressing applied. In cases of extreme deformity the end of the metatarsal bone should be excised, preferably by the method suggested by Fowler. This consists in making an incision between the first and second toes, open- ing the joint from the inside, strongly adducting the toe, and exposing the head of the metatarsal bone in the wound, removing the articular surface with bone-forceps or a saw, replacing the toe, and suturing the wound. After healing of the wound the toe should be maintained in proper position by a plantar splint of gutta-percha for several weeks. Hammer-toe. — Hammer-toe is a contraction of the second, third, or fourth toe, resulting in an acute flexion of the second phalanx and generally full extension of the third. This condition is frequently accompanied by an irritable callosity over the summit of the flexed joint, and may be exceedingly painful. In the earlier stages the deform- ity sometimes may be corrected by the use of splints or tenotomy; in the latter stages, however, excision of the interphalangeal joint or amputation at the metatarsophalangeal joint is to be recommended. Anterior Metatarsalgia. — This affection was first accurately described by Morton, of Philadelphia, and is often spoken of as Morton's painful joint. It consists in the occurrence of a severe and often spasmodic pain between the heads of the second and third, third and fourth, or fourth and fifth metatarsal bones. The pain usually comes on during walking, and generally is relieved by rest and removing the shoe. Exceptionally it occurs during rest, and may give rise to great suffering. It is often associated with weak foot, and has also been found to be accompanied by a breaking down of the anterior transverse arch. Treatment. — The treatment should consist in the wearing of prop- erly made shoes which do not compress the toes, and, if the transverse arch is broken down or rigid, a support should be fitted to correct this deformity. Club-hand. — Club-hand is an exceedingly rare condition of the upper extremity analogous to club-foot in the lower. The deformity may or may not be associated with abnormalities of the bony skeleton. As a rule, the hand is deflected, either in flexion or extension, toward the radial or ulnar side of the forearm. It is not infrequently associated with other congenital malformations. At an early" period after birth the deformity may often be cor- rected by manipulation and fixation with splints. Tenotomy or osteotomy may be required, and amputation is occasionally indicated. The results of tenotomy in the hand are less satisfactory than in the lower extremity, for the reason that failure of union often occurs, with consequent impairment of motion. Webbed Fingers (Syndactylism). — Webbed fingers is a congenital malformation in which two or more of the fingers are joined by either a thin cutaneous bridge or by a thick, fleshy mass. When the bridge is thin, it may be pierced at the base of the fingers and the opening TRIGGER-FINGER 981 allowed to heal, after which the thin bridge may be divided by scissors or a scalpel. If the bridge is thick, two cutaneous flaps should be raised, one from the palmar surface of one finger and another from the dorsal surface of the adjoining digit. After these flaps are dissected free the bridge of tissue is removed and the exposed surface of each finger covered by wrapping it with its own cutaneous flap, which is trimmed to fill exactly the freshened area, and sutured in place (Fig. 500). Supernumerary Fingers (Polydactylism). — Occasionally children are born with a complete or incomplete sixth digit. The malformation is frequently present in both hands. If useless or disfiguring, the extra finger should be removed. A similar condition is seen occasionally in the lower extremitv.. Fig. 500. — Webbed fingers. (Stimson.) Trigger-finger. — Trigger-finger is a condition in which the patient is able to close the fist, but on attempting to open it one finger remains for a fraction of a second flexed, and then flies open with a jerk, or is only opened by pressure of one of the other fingers, in which case it is extended in the same spasmodic manner. The cause of the affection is some interference with the smooth and even gliding of the tendon in its sheath, as a small fibroma or other tumor. In a case operated upon by Lilienthal the cause of the trouble was found to be a minute cyst in the interior of the tendon sheath. Treatment. — The treatment should consist in opening the sheath and removal of the cause. INDEX. Abdomen, cellulitis of, 507 contusions of, 500 diagnosis of, 501 treatment of, 502 diseases of, 507 injuries of, 500 extraperitoneal, 500 intraperitoneal, 500 wounds of, 504 non-penetrating, 504 penetrating, 504 symptoms of, 504 treatment of, 505 Abdominal aorta, ligation of, 274 distention following mechanical ileus, 186 mild, treatment of, 183 paralytic ileus and, 185 severe, treatment of, 183 treatment of, 181 prophylactic, during oper- ation, 182 post-operative, 182 organs, actinomycosis of, 70 wall, angioma of, 507 dermoid cysts of, 507 desmoids of, 508 epithelioma of, 507 fibroneuroma of, 507 lipoma of, 507 sarcoma of, 507 tumors of, 507 Abnormalities, congenital, of kidney, 600 Abrasion of skin, 229 Abscess, acute, definition of, 35 in acute general sepsis, 39 alveolar, 433 of anterior closed space, distal, 208 middle, 212 appendicular, 560 at base of fingers, 212 bone, 741 tuberculous, 751 of brain, 362 of chest-wall, 462 chronic, definition of, 37 of hypothenar eminence, 220 ischiorectal, 724 of kidney, 614 of liver, 571 Abscess, lumbar, 789 of lung, 470 of palm of hand, 212 of parotid gland, 390 of pericardium, 242 perinephritic, 616 peritonsillar, 432 of proximal closed space, 212 psoas, 789 diagnosis of, from femoral hernia, 932 retropharyngeal, 432, 789 of scalp, 332 of spleen, 596 subcutaneous, 197 treatment of, 198 submammary, 484 subperiosteal, 742 subphrenic, appendicitis and, 568 of subungual space, 205 of thenar eminence, 220 at web of fingers, 212 Accessory sinuses, diseases of, 422 spleen, 596 Acidosis, 116 Cheyne-Stokes, respiration in, 119 coma in, 119 convulsions in, 119 cyanosis in, 119 delirium in, 119 in diabetics, 117 dyspnea in, 119 jaundice in, 119 nausea in, 1 19 in non-diabetics, 118 symptoms of, 118 post-anesthetic, 118 symptoms of, 119 treatment of, 119 vomiting in, 119 Acinous carcinoma of breast, 492 Acromegaly, 755 symptoms of, 755 treatment of, 755 Acromial end of clavicle, dislocations of, 878 Acromion process of scapula, fracture of, 826 Actinomycosis, 68 of abdominal organs, 70 of bone, 752 of brain, 72 984 INDEX Actinomycosis, etiology of, G8 of face, 69 . of lung, 472 of neck, 69 pathologic anatomy of, 69 of peritoneum, 518 of skin, 72, 228 Streptothrix actinomyces in, 68 symptoms of, 69 of thorax, 70 treatment of, 72 Actinomycotic ulcers of rectum, 729 Acupunture in aneurism, 259 Adam's forceps in fractures of nasal bones, 821 Adenitis, femoral, diagnosis of, from femoral hernia, 932 Adenocarcinoma, 92 of bladder, 665 Adenocele of breast, 490 Adenoid growths, 429 treatment of, 429 Adenoma, 87 of intestine, 550 of kidney, 627 of liver, 574 of palate, 436 of rectum, 730 of testicle, 705 of trachea, 448 Adenomatous goitre, 400, 401 Adenopapilloma of breast, intracanalic- ular, 490 Adrenal gland, cysts of, 629 symptoms of, 630 treatment of, 630 hypernephroma of, 629 sarcoma of, 629 tumors of, 629 Agglutinins, 29 Aggressins, 25 Ainhum of skin, 229 Albert's disease, 302 Alcoholics, surgical risk in, 114 Alcoholism, shock and, 104 Alexins in acute inflammation, 32 Alveolar abscess, 433 Amastia, 483 Ammonium urate calculi, 657 Amputations, 944 at ankle-joint, 961 of arm, 955 Brewer's tourniquet in, 945 circular method of, 949 at elbow-joint, 954 of fingers, 952 general considerations of, 944 handling of tissues during, 946 hemostasis in, 945 at hip-joint, 957 interscapulothoracic, 956 kinetic stump in, 947 at knee-joint, 959 of leg, 961 Amputations, making of flaps in, 947 of metatarsophalangeal joints, 963 postoperative treatment of, 951 preparation for, 945 racket-shaped method of, 951 at shoulder-joint, 955 site of, 944 skin-Map method of, 949 skin- and muscle-flap method of, 950 Teale's method of, 950 of thigh, 959 time for, 944 of toes, 963 in tuberculosis of hip, 796 of joints, 787 at wrist, 954 Anastomosis, lateral, 557 by Murphy button, 555 of nerves, 318 Anatomical neck of humerus, fracture of, 831 Anemia in carcinoma of stomach, 532 pernicious, 598 in tuberculosis of cervical lymph nodes, 286 Anesthesia, 153 endopharyngeal insufflation, 162 general, 153 chloroform, 164 ether, 156 colonic absorption of, 167 nitrous oxide, 154 intratracheal insufflation, 161 indications for, 161 intravenous, 166 local, 168 infiltration, 169 regional method, 170 spinal, 170 surface application, 168 venous, 171 in wounds of nerve trunks, 304 Anesthetic shock, treatment of, 168 Anesthetometer, Connell's, 163 Aneurism, 249 acupuncture in, 259 aphonia in, 252 arteriovenous, 250 of bone, 763 cirsoid, 249 compression in, 253 development of, 249 diagnosis of, 251 dissecting, 249 dysphagia in, 252 dyspnea in, 252 edema in, 253 endo-aneurysmorrhaphv in, 258 false, 123, 249 fusiform, 249 galvanopuncture in, 259 ligature in, 256 miliar}', 249 INDEX 985 Aneurism needle, 2G9 pain in, 252 paralysis in, 252 pulse in, 253 of renal artery, 605 rupture of, 251, 252 saeeulated, 249 shock in, 253 syncope in, 253 syphilis and, 249 thoracic, 251 traumatic, 249 fractures and, 812 treatment of, 253 non-operative, 253 operative, 254 true, 249 varicose, 251 Aneurismal varix, 250 Angina Ludovici, 390 symptoms of, 390 treatment of, 390 Angioma, 84 of abdominal wall, 507 of brain, 368 cavernous, 85 of spleen, 599 of jaws, 436 of kidney, 627 of mouth, 436 of pharynx, 436 pulsating, 252 of rectum, 730 telangiectoides, 85 Ankle, dislocations of, 905 tuberculosis of, 798 symptoms of, 798 treatment of, 798 Ankle-joint, acute traumatic arthritis of, 773 amputation at, 961 Hey's operation for, 963 Lisfranc's amputation for, 963 Pirogoff s operation for, 961 Roux's operation for, 962 Skey's operation for, 963 Syme's operation for, 961 tuberculous arthritis of, 798 Ankylosis of joints, 804 Anoci-association, 172 in shock, 109 Anomalies of renal artery, 600 of thyroid gland, 398 Anterior closed spaces, 201 distal, abscess of, 208 treatment of, 209 with osteomyeli- tis of distal phalanx, 210 middle, abscess of, 212 tibial artery, ligation of, 276 Anthrax, 47 Bacillus anthracis and, 47 etiology of, 47 Anthrax, external, 47 of face, 391 internal, 47 intestinal, 47 respiratory, 48 symptoms of, 47 treatment of, 48 Antisepsis, 128 Antitoxins, 29 Anuria calculus, 623, 626 Anus, congenital malformations of, 723 disfases of, 723 fissures of, 729 symptoms of, 729 treatment of, 729 injuries of, 723 imperforate, 723 pruritus of, 729 treatment of, 730 Aorta, abdominal, ligation of, 274 Aphasia, motor, in tumors of brain, 369 Apoplexy, cerebral, 123 pancreatic, 589 Appendectomy, intermuscular, 564 Appendicitis, 559 acute catarrhal, 559 interstitial, 560 perforative, 560 sequela? of, 568 chronic, 566 course of, 562 diagnosis of, 562 fecal fistula and, 569 fever in, 561 gangrenous, 560 ^Ic•Burney's operation for, 564 point in, 560, 562 nausea in, 561 pain in, 561 portal thrombosis and, 568 pulse in, 561 recurrent, 559 relapsing, 559 subphrenic abscess and, 568 symptoms of, 560 treatment of, 563 postoperative, 567 ventral hernia and, 569 vomiting in, 561 Appendicular abscess, 560 colic, 559 dyspepsia, 566 Appendix, empyema of, 562 inflammation of, 559 Arm, amputation of, 955 test in tetany, 413 Arnold sterilizer, 132 Arterial hemorrhage, 123 Arteriovenous aneurism, 250 Arteritis, acute, 248 atheromatous, 248 chronic, 248 obliterative, 248 980 INDEX Artery or arteries, abdominal aorta, liga- tion of, 274 axillary ligation of, 272 brachial, ligation of, 273 carotid, common, ligation of, 270 external, ligation of, 271 internal, ligation of, 271 dorsalis pedis, ligation of, 277 facial, ligation of, 271 femoral, common, ligation of, 275 superficial, ligation of, 275 gluteal, ligation of, 275 iliac, common, ligation of, 274 external, ligation of, 275 internal, ligation of, 274 innominate, ligation of, 270 ligation of, 268 lingual, ligation of, 271 occipital, ligation of, 271: peroneal, ligation of, 277 popliteal, ligation of, 276 radial, ligation of, 273 sciatic, ligation of, 275 subclavian, ligation of, 271 temporal, ligation of, 271 thyroid, inferior, ligation of, 272 superior, ligation of, 271 tibial, anterior, ligation of, 276 posterior, ligation of, 276 ulnar, ligation of, 273 vertebral, ligation of, 272 Arthritis, 772 acute, 772 infective, 773 arthrotomy in, 775 diplococcus in, 774 etiology of, 773 gonococcus in, 774 pathology of, 773 pneumococcus in, 774 staphylococcus in, 774 streptococcus in, 774 symptoms of, 773 treatment of, 775 varieties of, 774 traumatic, 772 ankle-joint in, 773 effusion in, 772 elbow-joint in, 772 hip-joint in, 772 knee-joint in, 773 pain in, 772 shoulder-joint in, 772 symptoms of, 772 treatment of, 773 wrist-joint in, 772 ankylopoitica, 777 chronic, 776 course of, 780 etiology of, 777 pain in, 779 pathology of, 777 primary hypertrophic, 782 treatment of, 782 Arthritis, chronic, symptoms of, 778 treatment of, 780 local, 781 ulcerative, 782 villous, 782 etiology, 782 treatment of, 782 x-rays in, 780, 781 deformans, 777 in children, 782 etiology of, 782 symptoms of, 782 treatment of, 782 gouty, 776 infective, secondary, 776 rheumatoid, 777 senile, 782 suppurative, of interphalangeal joints, 211 of metacarpophalangeal joint, 211 syphilitic, 782 symptoms of, 783 treatment of, 783 tuberculous, 783 of ankle-joint, 798 of elbow,' 800 of hip-joint, 794 of knee-joint, 796 pain in, 785 pathology of, 784 of shoulder, 799 symptoms of, 785 toxemia in, 785 treatment of, 786 operative, 787 of wrist, 800 Arthrodesis, 805 Arthropathy, neuropathic, 801 symptoms of, 802 treatment of, 802 Arthrotomy in acute infective arthritis, 775 in tuberculosis of joints, 787 Articulations, carpometacarpal, disloca- tions of, 894 inferior radio-ulnar, dislocations of, 892 mediocarpal, dislocations of, 893 radiocarpal, dislocations of, 893 Artificial limbs, use of, 952 pneumothorax, 477 Ascending infections of kidney, 608 spiral bandage, 134 Ascites, chylous, 278 cirrhosis of liver and, surgical treat- ment of, 574 Asepsis, 128 Aspiration of pericardium, 243 Astereognosis in tumors of brain, 369 Astragalus, dislocations of, 907 forward, 907 outward, 907 treatment of, 907 INDEX 987 Astragalus, fractures of, 870 diagnosis of, 871 Asymmetrical goitre, 400 Ataxia in tumors of brain, 369 Atheromatous arteritis, 248 dermoid cysts of skin, 235 Atlas of spine, fracture of, 378 Atony of bladder, 671 Atrophy, hernia and, 913 of skin in varicose veins, 264 Auditopsychic area of brain, 347 Auditosensory area of brain, 347 Autoclave, steam, 132 Avulsion of scalp, 330 Axillary abscess of chest-wall, 463 artery, ligation of, 272 Axis of spine, fracture of, 378 B Bacillus aerogenes capsulatus infec- tions, 50 diagnosis of, 51 treatment of, 51 anthracis, anthrax and, 47 gas, 50 of glanders, 49 of malignant edema, 48 mallei, 50 tuberculosis, 58 Backache following operations, treat- ment of, 179 Bacteria, action of, in body, 27 of bronchi, 22 of genito-urinary tract, 23 infection with, external sources, 19 internal sources, 21 portals of entry of, 19 inflammation of joints and, 771 of intestines, 22 of larynx, 22 of mouth, 21 of pharynx, 21 of respiratory passages, 21 of skin, 20 of stomach, 22 Bacterial excitant, 25 host, 26 Bacteriuria, 652 symptoms of, 653 treatment of, 653 Balanitis, 688 Balanoposthitis, 688 Bandage, ascending spiral, 134 figure-of-eight, 134 handkerchief, 139 many-tailed, 139 modified Velpeau, 137 plaster-of-Paris, 142 recurrent, 136 roller, 134 spica, 134 spiral reversed, 134 Bandage, T-, 139 triangular, 139 two-tailed jaw, 141 Bandaging, 133 Basal-celled epithelioma, 193 Basedow's disease, 404 Bassini's operation for inguinal hernia, 925 Bed-sores, 57 Bennett inhaler, 160 Bigelow lithotrite, 660 Bilharzia hematoma, hematuria and, 654 Biliary passages, diseases of, 575 Binder, breast, 138 "Birth marks," 267 Bladder, adenocarcinoma of, 665 atony of, 671 carcinoma of, 665 congenital malformations of, 646 contusions of, 647 diseases of, 650 diverticula of, 647 double, 647 epithelioma of, 665 exstrophy of, 646 treatment of, 647 fibromyxoma of, 665 foreign bodies in, 650 . treatment of, 650 functional affections of, 670 inflammation of, 650 injuries of, 647 implantation of ureter into, 645 painful neuroses of, 671 treatment of, 672 papilloma of, 665 paralysis of, 671 rupture of, 648 shock in, 648 symptoms of, 648 treatment of, 649 sarcoma of, 665 stone in, 657. See Vesical calculus, trabeculated, 681, 711 tuberculosis of, 655 cystoscopy in, 656 diagnosis of, 656 nephrectomy in, 656 pain in, 656 symptoms of, 655 treatment of, 656 tumors of, 664 cystitis in, 666 diagnosis of, 666 dysuria in, 665 hematuria in, 665 pain in, 665 prognosis of, 666 suprapubic lithotomy in, 666 symptoms of, 665 treatment of, 666 urine in, 665 villous, 665 wounds of, 647 INDEX Blake's operation for femoral hernia, 933 for inguinal hernia, 928 for umbilical hernia, 937 Blastomycetes, 72 Blastomycosis, 72 of skin, 228 treatment of, 73 Bleeders, definition of, 123 Blood, transfusion of, 149 Bloodgood's operation for inguinal her- nia, 927, 929 Blood-pressure in compression of brain, 3.55 in shock, 102 Bloodvessels, diseases of, 248 fatty degeneration of, 248 hernia and, 911 inflammation of, 248 media of, calcification of, 248 tumor of, 249. See Aneurism, wounds of, 248 Boas-Oppler bacillus in carcinoma of stomach, 532 in pyloric stenosis, 529 Bodv of scapula, fracture of, 827 Boils, 194 Bone or bones, actinomycosis of, 752 treatment of, 753 aneurism of, 763 carcinoma of, 765 caries of, 753 carpal, dislocations of, 893 fractures of, 850 chondroma of, 758 cranial, syphilis of, 343 tuberculosis of, 343 cysts of, 760 symptoms of, 760 treatment of, 760 degeneration of, 756 diffuse periosteal thickening of, 753 diseases of, 741 of face, fractures of, 820 fibroma of, 760 of foot, fractures of, 870 gangrene of, 753 of hand, dislocations of, 894 hypertrophy of, 755 inflammation of, 741 sequelae of, 753 lipoma of, 760 of lower extremity, fractures of, 852 metatarsal, dislocations of, 907 fractures of, 871 myeloma of, 762 multiple, 765 nasal, fractures of, 820 necrosis of, 753 nutritive disturbances of, 753 osteoma of, 758 Paget's disease of, 754 sarcoma of, 760 central, 761 diagnosis of, 763 Bone or bones, sarcoma of, medullary 761 periosteal, 761 peripheral, 761 prognosis of, 764 treatment of, 764 .c-iays in, 761 sclerosis of, 753 semilunar, dislocations of, 893 syphilis of, 749 pain in, 750 symptoms of, 750 treatment of, 750 tarsal, dislocations of, 907 of trunk, fractures of, 823 tuberculosis of, 751 symptoms of, 751 treatment of. 751 x-rays in, 751 tumors of, 758 ulceration of, 753 of upper extremities, fractures of, 826 Bone-abscess, 741 tuberculous, 751 Bougie, bulbous, 684 olive-pointed, 684 Bowel, obstruction of, 550 strangulation of, 550 ulcers of, 544. See Intestine, ulcers of. Bow-legs, 971 diagnosis of, 972 treatment of, 973 Brachial artery, ligation of, 273 nerves, paralysis of, 320 operations for, 320 Bradford frame in Pott's disease, 791 Brain, 344 abscess of, 362 course of, 362 symptoms of, 362 treatment of, 363 actinomycosis of, 72 angioma of, 368 areas of, 346, 347 auditopsychia, 347 auditosensory, 347 motor, 346 olfactory, 348 postcentral. 347 precentral. 34tj visuopsychic, 347 visuosensory, 347 compression of, 354 blood-pressure in, 355 Chevne-Stokes respiration in, 355 paralysis in, 355 prognosis of, 355 pulse in, 355 treatment of, 355 concussion of, 352 diagnosis of, 353 INDEX 989 Brain, concussion of, mild, 353 severe, 353 symptoms of, 352 treatment of, 354 contusion of. 356 prognosis of, 356 symptoms of, 356 treatment of, 356 cysts of, 368 diseases of, 359 endothelioma of, 368 fibroma of, 368 glioma of, 368 inflammation of, 359 injuries of, 352 lacerations of, 356 prognosis of, 356 symptoms of, 356 treatment of, 356 membranes of, contusions of, 356 inflammation of, 359 laceration of, 356 neuroma of, 368 of newborn, injuries of, 367 operations on, 371 prolapse of, 366 treatment of, 366 sarcoma of, 368 sinuses of, thrombosis of, 363 exophthalmos in, 363 symptoms of, 363 treatment of, 364 tumors of, 368 astereognosis in, 369 ataxia in, 369 choked disk in, 369 deafness in, 369 dysphagia in, 369 gait in, 369 headache in, 368, 370 hemianesthesia in, 369 hemianopsia in, 369 hemiplegia in, 369 Jacksonian epilepsy in, 369 motor aphasia in, 369 nystagmus in, 369 optic neuritis in, 368 pain in, 369 prognosis of, 370 symptoms of, 368 syphilis and, 370 tinnitus in, 369 treatment of, 370 tuberculosis and, 370 vertigo in, 368 vomiting in, 368, 369 Branchial cleft, carcinoma of, 395 cysts, 393 fistula?, 392 Breast, adenocele of, 490 binder, 138 carcinoma of, 492 acinous, 492 diagnosis of, 496 Breast, carcinoma of, duct, 495 encephaloid, 495 operation for, 497 Halstead's, 498 prognosis of, 496 scirrhus, 493 symptoms of, 4 '.)."> treatment of, 497 ar-rays in, 499 chondrosarcoma of, 491 congenital absence of, 483 cyst-adenoma of, 488, 490 cyst osar coma of, 491 fibro-adenoma of, 489, 490 diagnosis of, 490 treatment of, 41)1 fibrocyst-adenoma of, 490 hypertrophy of, diffuse virginal, 487 treatment of, 488 senile parenchymatous, 488 symptoms of, 489 intracanalicular adenopapilloma of, 490 myxoma of, 490 malformations of, 483 myxosarcoma of, 491 Paget's disease of, 90, 487 sarcoma of, 491 diagnosis of, 491 treatment of, 492 syphilis of, 485 tuberculosis of, 486 treatment of, 486 tumors of, 489 Brewer's dressing for Colles' fracture, 848 empyema drainage tube, 468 tourniquet in amputations, 945 Bronchi, bacteria of, 22 dilatation of, 471 symptoms of, 471 treatment of, 471 Bronchiectasis, 471 symptoms of, 471 treatment of, 471 Bronchocele, 399 Brophy's operation for cleft palate, 420 Brown's wire suture in ehiloplasty, 418 Bryant's empyema drainage tube, 467 Bubo, chancroidal, 689 Bubonocele, 923 Buck's extension apparatus in fractures of femur, 857 Bulb and parachute snare, 443 Bulbous bougie, 684 Bunions, 302 treatment of, 302 Burns of scalp, 330 of skin, 189 treatment of, 190 Bursa, extension of infection from, 221 Bursa?, adventitious, 300 anatomic, 300 contusions of, 300 diseases of, 300 990 INDEX Bursa?, inflammation of, 300 injuries of, 300 tumors of, 302 Bursitis, acute, 300 chronic, 300 treatment of, 301 subacromial, 301 treatment of, 302 subdeltoid, 301 treatment of, 302 trade, 302 Cachexia strumipriva, 412 Calcaneus, fractures of, 870 diagnosis of, 871 Calcification of media of bloodvessels, 248 Calcium oxalate calculi, 657 Calculi, ammonium urate, 657 calcium oxalate, 657 cystine, 658 phosphate, 657 prostatic, 7 10 uric acid, 657 xanthine, 658 Calculus anuria, 623, 626 nephrotomy in, 627 pain in, 626 prognosis of, 627 symptoms of, 626 treatment of, 627 ureterotomy in, 627 z-rays in, 627 renal, 622 ureteral, 635 urethral, 687 vesical, 657 Cancer, 87. See Carcinoma. en cuirasse, 494 Cancrum oris, 57 Cannula, Crile's transfusion, 149 Konig's spiral, 451 Capillary hemorrhage, 123 Carbolic gangrene, 55 Carbuncle, 198 of face, 391 of neck, 391 treatment of, 199 Carcinoma, 87 of bladder, 665 of bone, 765 of branchial cleft, 395 of breast, 492 acinous, 492 duct, 495 encephaloid, 495 scirrhus, 493 colloid, 89 cylindrical, 87, 91 duct, 91 encephaloid, 91 Carcinoma of gall-bladder, 583 of gall-ducts, 584 of intestine, 551 of kidney, 628 of liver, 574 of lung, 474 of lymph nodes, 293 of mediastinum, 476 of pancreas, 593 of parotid gland, 398 of prostate gland, 715 of rectum, 731 scirrhus, 90 of skin, 238 spheroidal, 87, 90 of spleen, 599 squamous, 87, 92 of stomach, 530 of sublingual gland, 398 of submaxillary gland, 398 of testicle, 705 of thyroid gland, 411 of tongue, 435 Carcinomatous ulcers of skin, 234 Garden's method of amputation at knee- joint, 960 Cardiac massage in wounds of heart, 247 weakness, 120 Cardiolysis, 244 Cardiospasm, 529 symptoms of, 529 treatment of, 529 Caries of bone, 753 Carotid artery, ligation of, 270 Carpal bones, dislocations of, 893 fractures of, 848 symptoms of, 848 treatment of, 848 Carpometacarpal articulations, disloca- tions of, 894 Cartilage, floating, in joint, 769 semilunar, dislocations of, 903 Castration, 716 Catarrhal appendicitis, 559 cholecystitis, 580 Catheter, flexible, 148 Mercier's coude, 148 metallic, 148 prostatic, 148 Catheterism in senile hypertrophy of prostate gland, 713 Catheterization, 147 Catheter, Gouley's, 684 Cauda equina, injuries of, 382 Cavernous angioma, 85 of spleen, 599 lymphangioma, 85 Cellulitis, 195 of abdomen, 507 acute mediastinal, 475 causes of, 195 in erysipelas, 41 gangrenous, 56 of neck, 389 INDEX '.)<)! Cellulitis of penis, 688 of scalp, 331 of scrotum, (588 symptoms of, 19(5 treatment of, 196 operative, 196 Cephalagia, traumatic, 367 Cerebellum, lesions of, 340 Cerebral apoplexy, 123 hemisphere, cortex of, 345 injuries of newborn, 367 palsy, infantile, 367 Cerebrospinal meningitis, 360 Cervical lymph nodes, tuberculosis of, 285 sympathetic nerves, resection of, for exophthalmic goitre, 318 for glucoma, 318 Chain-stitch suture, 145 Chancre, 62 of penis, 690 Chancroid, phagedenic, 689 Chancroidal bubo, 689 ulcers of rectum, 728 Charcot's disease of joints, 801 Cheek, epithelioma of, 434 Cheever's lateral pharyngotomy, 439 Chemosis in thrombosis of sinuses of brain, 363 Chemotaxis in acute inflammation, 32 Chest binder, sling and, 141 Chest-wall, abscess of, 462 axillary, 463 subpectoral, 462 chrondroma of, 464 contusions of, 459 treatment of, 459 cysts of, dermoid, 463 echinococcus, 463 sebaceous, 463 diseases of, 462 epithelioma of, 464 fibroma of, 463 molluscum of, 463 injuries of, 459 lipoma of, 463 osteoma of, 463 sarcoma of, 463, 464 tumors of, 463 prognosis of, 464 treatment of, 464 wounds of, 460 chylothorax and, 460 hemothorax and, 460 pneumothorax and, 460 treatment of, 461 Cheyne-Stokes' respiration in acidosis, 119 in compression of brain, 355 in uremia, 122 Chiloplasty, 417 Brown's wire suture in, 418 Lane's suture in, 418 Chiloplasty, Mirault's operation, 418 Simon's operation, 418 Chismore evacuator, 660 Chloroform, administration of, 164, 165 after-effects of, 165 indications for, 164 Choked disk in tumors of brain, 369 Cholangitis, 582 prognosis of, 583 symptoms of, 582 treatment of, 583 Cholecystectomy, 586 Cholecystenterostomy, 587 Cholecystitis, 579 catarrhal, 580 chills in, 581 fever in, 581 gangrenous, 580 pain in, 580, 581 prognosis of, 581 suppurative, 580 symptoms of, 580 treatment of, 582 vomiting in, 581 Cholecystotomy, 585, 586 Choledochotomy, 586 transduodenal, 587 Cholelithiasis, 575 acute pancreatitis in, 578 complications of, 578 fever in, 578 jaundice in, 577 pain in, 576 prognosis of, 578 sepsis in, 578 skin in, 578 symptoms of, 576 treatment of, 579 urine in, 578 Chvostek's symptom in tetany, 413 Chylangioma, 85 Chylothorax, 278, 465 treatment of, 278 wounds of chest-wall and, 460 Chylous ascites, 278 treatment of, 278 hydrocele, 697 Chondrodystrophia, 756 Chondroma, 79 of bone, 758 of chest-wall, 464 of joints, 803 of spinal cord, 383 of trachea, 448 Chondrosarcoma of breast, 491 Chorionepithelioma, 95 Cigarette drain, 143 Circular enterorrhaphy, 554 method of amputation, 949 Circulatory ulcers of skin, 230 Circumcision in phimosis of penis, 690 Cirrhosis of liver, ascites and, surgical treatment of, 574 of spleen, hypertrophic, 599 992 INDEX Cirsoid aneurism, 249 Clavicle, dislocations of, 878 of acromial end of, 878 diagnosis of, 879 downward, 878 treatment of, 879 upward, 878 of sternal end of, 878 diagnosis of, 878 treatment of, 878 fractures of, 828 complications of, 829 diagnosis of, 829 Moore's dressing for, 828 Sayre's dressing for, 830 treatment of, 829 Clavus, 228 treatment of, 228 Cleft palate, 415 Brophy's operation for, 420 Lane's operation for, 421 Langenbeck's operation for, 421 operations for, 420 staphylorrhaphy for, 420 uranoplasty for, 420 Club-foot, 973 congenital, 973 treatment of, 975 Club-hand, 980 Cocaine in local anesthesia, 168, 170 Coin-catcher, 442 Colic, appendicular, 559 Colles' fracture, 843 Brewer's dressing for, 848 complications of, 846 diagnosis of, 844 prognosis of, 846 treatment of, 846 law in congenital syphilis, 66 Colloid carcinoma, 89 of stomach, 531 goitre, 400 Colon bacillus, acute osteomyelitis and, 741 dilatation of, congenital idiopathic, 569 prognosis of, 570 symptoms of, 569 treatment of, 570 Colonic absorption of ether, anesthesia by, 167 Colostomy, 558 Comminuted fractures, 806 Common carotid artery, ligation of, 270 femoral artery, ligation of, 275 iliac artery, ligation of, 274 Composite odontome, 436 Compound fractures, 806 Compression of brain, 354 of nerve trunks, 306 Concussion of brain, 352 of spinal cord, 380 Condyles of femur, fractures of, 862 of humerus, fracture of, 838 Congenital absence of breast, 483 of urethra, 672 anomalies of spleen, 596 club-foot, 973 cysts, 99 dislocations, 873 of hip, 966 hydrocele, 697 idiopathic dilatation of colon, 569 inguinal hernia, 922 malformations of anus, 723 of bladder, 646 of rectum, 723 rickets, 756 spastic paralysis, 367 stricture of rectum, 723 syphilis, 66 umbilical fistula;, 507 hernia, 934 Connective tissue tumors, 77 Cornell's anesthetometer, 163 Continued suture, 145 Contusions of abdomen, 500 of bladder, 647 of brain, 356 of bursa?, 300 of chest-wall, 459 of face, 387 of joints, 766 of kidney, 603 of membranes of brain, 356 of muscles, 294 of neck, 387 of nerves, 303 of penis, 688 of scalp, 326 of scrotum, 688 of skin, 192 of spinal cord, 380 of testicle, 700 of urethra, 674 Coracoid process of scapula, fracture of, 090 Corn, 228 treatment of, 228 Coronoid process, fractures of, 841 symptoms of, 841 treatment of, 841 Corpora quadrigemina, lesions of, 348 Corpus callosum, lesions of, 348 Costal cartilages, fractures of, 824 diagnosis of, 824 prognosis of, 824 treatment of, 824 Cowper's gland, cysts of, 687 Coxa valga, 969 vara, 968 symptoms of, 969 treatment of, 969 Cranial bones, syphilis of, 343 pathology of, 344 symptoms of, 344 treatment of, 344 tuberculosis of, 343 INDEX Hodgkin'a disease, 291 treatment of, 293 Hoffa's treatment of congenital disloca- tion of hip, ( .>07 Holzphlegmon, 389 Horse-hair probang, 442 Hotchkiss' operations for sliding hernia, 942 Hour-glass stomach, 530 Housemaid's knee, '■'>"'- Humerus, fractures of, 831 of anatomical neck of, 831 of external condyle of, 838 of lower extremity of, 835 complications of, 838 diagnosis of, 835 treatment of, 838 operative, 840 of shaft of, 834 diagnosis of, 835 treatment of, 835 of surgical neck of, 831 of tuberosities of, 831 of upper extremity of, 831 complications of, 832 diagnosis of, 831 prognosis of, 832 treatment of, 832 Hydatid cysts. 98 of liver, 573 of pancreas. 594 Hydatiform mole, 95 Hydrocele. 695 acute, 695 bilocular, 697 chronic, 695 chylous, 697 congenital, 697 of cord, 697 double, 697 treatment of, 697 Hydrocephalus, 364 treatment of, 365 Hydro-encephalocele, 365 treatment of, 366 Hydronephrosis, 633, 634 intermittent, 634 symptoms of, 634 treatment of, 634 x-rays in, 634 Hydrophobia. 45 etiology of, 45 morbid anatomy of, 45 symptoms of, 46 treatment of, 46 Hydrops articulorum intermittens, 802 Hydrothorax, 465 symptoms of, 465 treatment of, 405 Hygromata of neck, 394 Hyperchlorhydria in gastric ulcer, 522 Hypernephroma, 96 Hypernephroma of adrenal gland, 629 of kidney. 627 Hyperplasia of lymph nodes, 291 Hyperthyroidism, 404 Hypertrophic arthritis, 782 osteo-arthritis, 7_'7 Hypertrophy of bone, 755 of breast, diffuse virginal, 487 of prostate gland, 710 Hypodermoclysis, 152 Hypospadias, 072 glandular. 072 perineal, 672 treatment of, 673 Hypothenar eminence, abscess of, 820 Ichthyosis of tongue, 432 Icterus, hemolytic, 598 Idiopathic multiple hemorrhagic sar- coma of skin, 239 osteomyelitis, 741 Ileocecal tuberculosis, 546 symptoms of, 546 treatment of, 546 Ileus, 540 gastro mesenteric, 519 mechanical, abdominal distention following, 186 paralytic, abdominal distention fol- lowing, 185 Iliac artery, ligation of, 274 dislocation of hip, 879 Immunity, 28 active, 29 passive, 30 Impacted fractures, 806 Imperforate anus, 723 Implantation of ureter into bladder. 645 Incarcerated hernia, 914 Incontinence of urine, 071 Indigo-carmine test in examination of urine, 639 Indolent ulcers of skin, 231 Infantile inguinal hernia, 922 paralysis, 323 umbilical hernia, 935 Infection, surgical relation of, 17 terminal, 28 Infections, cryptogenetic, 38 Infective granulomata, 34, 35 ulcers of skin, 230 Infiltration anesthesia, 169 Inflamed hernia, 917 ulcers of skin, 230 Inflammation, 31 acute, 31 alexins in, 32 chernotaxis in, 32 cicatrization in, 34 fever in, 32 leukocytosis in, 32 1004 INDEX Inflammation, acute, loss of function in, 32 pain in, 32 phagocytosis in, 32 pyogenic organism in, 32 redness in, 31 resolution in, 34 swelling in, 31 symptoms of, 31 general, 32 local, 31 of bladder, 650 of bloodvessels, 248 of bone, 741 of brain, 359 chronic, 34 of dura mater, 359 of ear, 457 of epididymis, 700 of face, 388 of frontal sinus, 427 gangrenous, 56 of joints, 770 of kidney, 608 of lymph nodes, 281 of mammary gland, 483 of maxillary antrum, 426 of mediastinum, 475 of membranes of brain, 359 of muscles, 296 of neck, 388 of nerves, 307. See Neuritis, of pancreas, 588 of parotid gland, 390 of penis, 688 of pi a mater, 360 of prostate gland, 708 of rectum, 724 of salivary glands, 433 of scalp, 331 of scrotum, 688 of seminal vesicle, 706 of skin, 194 of tendons, 297 of testicle, 702 of thyroid gland, 4 1 1 of tongue, 432 of ureter, 633 of urethra, 676 of veins, 260. See Phlebitis. Inflammatory exudate in pericardium, 241 stricture of rectum, 726 Infracotyloid dislocations of hip, 899 Infusion, intravenous, of salt solution, 151 Ingrowing toe-nail, 206 operation for, 207 treatment of, 206 Inguinal hernia, 921 congenital, 922 infantile, 922 Inhaler, Bennett, 160 Esmarch, 158 Innominate artery, ligation of, 270 Insufflation anesthesia, intratracheal, 161 Intercondyloid fractures of femur, 863 Intermediate precentral area of brain, 347 Intermuscular appendectomy, 564 Internal carotid artery, ligation of, 271 iliac artery, ligation of, 274 Interphalangeal joints, suppurative ar- thritis of, 211 Interrupted suture, 145 Interscapulothoracic amputation, 956 Interstitial appendicitis, acute, 560 hernia, 929 Intestinal obstruction, acute, 540 etiology of, 540 intussusception and, 540 pain in, 541 prognosis of, 542 symptoms of, 541 treatment of, 542 volvulus and, 541 vomiting in, 541 chronic, 543 symptoms of, 543 treatment of, 544 Intestine, adenoma of, 550 bacteria of, 22 carcinoma of, 551 cysts of, 550 diseases of, 540 diverticula of, 546 acquired, 547 congenital, 547 fibroma of, 550 large, hernia of, 940 myxoma of, 550 obstruction of, 540. See Intestinal obstruction, operations on, 553 papilloma of, 551 sarcoma of, 551 tuberculosis of, 546 hyperplastic, 546 tumors of, 550 symptoms of, 551 treatment of, 552 ulcers of, 544 dysenteric, 545 treatment of, 545 typhoid perforation and, 544 prognosis of, 545 symptoms of, 545 treatment of, 545 Intracanalicular adenopapilloma of breast, 490 myxoma of breast, 490 Intracerebral hemorrhage, 358 Intracranial hemorrhage, 356 neurectomy, 311 Intramedullary hemorrhage, 380 Intraperitoneal injuries of abdomen, 500 Intrathoracic goitre, 411 Intravenous anesthesia, 166 Intubation instruments, O'Dwyer's, 453 of larynx, 451 IX DUX 1005 Intussusception, intestinal obstruction and, 540 Irreducible hernia, 913 Irrigating solutions, preparation of, 132 Ischemic gangrene, .">."> paralysis, fractures and, 810 Ischiorectal abscess, 724 Isthmectomy in simple goitre, 404 Jacksonian epilepsy, 367 Jaundice in abscess of liver, 571 in acidosis, 119 in carcinoma of gall-ducts, 584 in cholelithiasis, 577 in pancreatitis, 591, 592 Jaw, angioma of, 436 ' bandage, two-tailed, 141 diseases of, 431 dislocation of, 876 bilateral, 877 diagnosis of, 877 treatment of, 877 lipoma of, 436 lower, fractures of, 822 Gunning's interdental splint in, 823 symptoms of, 822 treatment of, 822 removal of, 439 lumpy, 68 lymphangioma of, 436 odontoma of, 436 operations on, 437 osteoma of, 436 osteomyelitis of, 433 diagnosis of, 433 treatment of, 433 papilloma of, 436 sarcoma of, 435 tumors of, 434 upper, fractures of, 822 symptoms of, 822 treatment of, 822 removal of, 439 Joints, ankylosis of, 804 treatment of, 804 Charcot's disease of, 801 symptoms of, 802 treatment of, 802 chondroma of, 803 contusions of, 766 diseases of, 766 dislocations of, 770 floating cartilage in, 769 pain in, 769 symptoms of, 769 treatment of, 769 fractures of, 770 inflammation of, 770 bacteria and, 771 chemical irritation and, 770 Joints, inflammation of, etiology of, 770 pathology of, 771 pyorrhea alveolaris and, 771 trauma and, 770 injuries of, 766 interphalangcal, suppurative arthri- tis of, 211 lipoma of, 804 Morton's painful, 980 osteoma of, 803 sacro-iliac, tuberculosis of, 801 sprains of, 766 ecchymosis in, 766 pain in, 766 symptoms of, 766 treatment of, 767 syphilis of, 782 symptoms of, 783 treatment of, 783 tuberculosis of, 783 amputation in, 787 arthrotomy in, 787 etiology of, 783 operations in, 787 pain in, 785 pathology of, 784 symptoms of, 785 toxemia in, 785 treatment of, 786 tumors of, 803 wounds of, 768 symptoms of, 768 treatment of, 768 Kelly's protoscope, 727 Keloid of skin, 237 Keyes' deep urethral syringe, 679 Kidney, abscess of, 614 prognosis of, 615 symptoms of, 615 treatment of, 615 adenoma of, 627 angioma of, 627 carcinoma of, 628 congenital abnormalities of, 600 contusions of, 603 cysts of, 629 dermoid, 629 echinococcus, 629 simple serous, 629 dermoids of, 627 exposure of, 639 oblique lumbar incision in, 640 posterior vertical incision in, 639 fibroma of, 627 hypernephroma of, 627 infections of, ascending, 608 acute, 610 hematogenous, 609 acute unilateral, 611 looi; INDEX Kidney, infections of, hematogenous, acute unilat- eral, diagnosis of, 612 prognosis of, 613 treatment of, 613 inflammation of, 608 injuries of, 602 subparietal, 602 fever in, 603 hematuria in, 603 pain in, 603 prognosis of, 604 symptoms of, 603 treatment of, 604 a>rays in, 046 lipoma of, 627 movable, 606 Dietls' crisis in, 607 nausea in, 607 pain in, 607 prognosis of, 608 symptoms of, 607 treatment of, 608 vomiting in, 607 myxoma of, 627 operations on, 638 papilloma of, 627 polycystic, 629 treatment of, (>2!t rupture of, 603 sarcoma of, 628 syphilis of, 617 symptoms of, 617 treatment of, 618 tuberculosis of, 618 diagnosis of, 620 fever in, 619 nephrectomy for, 621 pain in, 619 polyuria in, 619 prognosis of, 621 symptoms of, 619 treatment of, 621 urine in, 619 tumors of, 627 hematuria in, 628 pain in, 628 symptoms of, 628 urine in, 628 wounds of, open, 605 Kinetic stump in amputation, 947 theory of shock, 103 Knee, dislocations of, 901 backward, 902 diagnosis of, 902 forward, 902 lateral, 902 prognosis of, 903 rotary, 902 treatment of, 903 tuberculosis of, 796 excision in, 798 operation in, 797 Knee, tuberculosis of, symptoms of, 798 Thomas splint in, 797 treatment of, 797 Knee-joint, amputation at, 959 bilateral flap method of, 959 Garden's method of, 960 Gritti's method of, 960 Stoke's method of, 960 traumatic arthritis in, 773 tuberculous arthritis of, 796 Knock-knee, 969 diagnosis of, 969 treatment of, 970 Knot, granny, 144. 145 reef, 144 surgeon's, 144, 145 Kocher's method of reduction of dis- location of shoulder, 886 sign in exophthalmic goitre, 406 Konig's spiral cannula, 451 Kyphosis in Pott's disease, 789 Lacerations of brain, 356 Laminectomy in fracture of spine, 379 in operations on spine, 386 Lane's operation for cleft palate, 421 suture in chiloplasty, 418 Langenbeck's operation for cleft palate, 421 Laryngectomy, 452 Larynx, bacteria of, 22 diseases of, 440 epithelioma of, 446 extrinsic, 446 intrinsic, 446 prognosis of, 447 symptoms of, 447 treatment of, 447 fibroma of, 446 foreign bodies in, 440 treatment of, 441 intubation of, 451 operations on, 449 papilloma of, 446 syphilis of, 448 tuberculosis of, 448 tumors of, 446 wounds of, 388 Lateral anastomosis, 557 lithotomy in vesical calculus, 663 Leg, amputation of, 961 fractures of both bones of, 866 lower, fractures of, 866 compound, 870 diagnosis of, 867 prognosis of, 868 traction in, 869 treatment of, 868 phenomena in tetany, 413 varicose veins of, 261 Leiomyoma, 85 INDEX 1007 Leontiasis, 755 treatment of, 755 Leptomeningitis, acute septic, 300 lumbar puncture in, 301 paralysis in, 301 prognosis of, 301 symptoms of, 300 treatment of, 301 Leukemia, lymphatic, 293 Leukocytosis in acute general sepsis, 39 inflammation, 32 pancreatitis, 590 in angina Ludovici, 390 in erysipelas, 41 in perinephritic abscess, 017 Leukoplakia of tongue, 432 Levis' extension apparatus in disloca- tions of phalanges of hand, 890 Ligation of abdominal aorta, 274 of anterior tibial artery, 270 of axillary artery, 272 of brachial artery, 273 of carotid artery, 270 of common carotid artery, 270 femoral artery, 275 iliac artery, 274 of dorsalis pedis artery, 277 of external carotid artery, 271 iliae artery, 275 of facial artery, 271 of gluteal artery, 275 of iliac artery, 274 of inferior thyroid artery, 272 of innominate artery, 270 of internal carotid artery, 271 iliac artery, 274 of lingual artery, 271 of occipital artery, 271 of peroneal artery, 277 of popliteal artery, 270 of posterior tibial artery, 270 of radial artery, 273 of sciatic artery, 275 of subclavian artery, 271 of superficial femoral artery, 275 of superior thyroid artery, 271 in exophthalmic goitre 410 of temporal artery, 271 of ulnar artery, 273 of vertebral artery, 272 Ligatures, 144, 145 in aneurism, 250 gangrene and, 55 Linea semilunaris, hernia in, 939 transversse, hernia in, 939 Lingual artery, ligation of, 271 goitre, 410 thyroid, 410 Lip, epithelioma of, 397 treatment of, 397 Lipoma, 78 of abdominal wall, 507 arborescens, 804 Lipoma of bone, 700 of chest-wall, 403 of face, 390 of jaws, 430 of joints, 804 of kidney, 027 of mediastinum, 470 of mouth, 430 of neck, 390 of pharyux, 430 of rectum, 730 of scalp, 333 of scrotum, 092 of spinal cord, 383 of trachea, 448 Lisfranc's operation for amputation at ankle-joint, 903 Litholapaxy in vesical calculus, 000 Lithotomy, lateral, in vesical calculus, 003 suprapubic, in tumors of bladder, 000 in vesical calculus, 001 Lithotrite, Bigelow's, 000 Littre's hernia, 919 Liver, abscess of, 571 symptoms of, 571 treatment of, 572 adenoma of, 574 carcinoma of, 574 cirrhosis of, ascites and, surgical treatment of, 574 cysts of, hydatid, 573 symptoms of, 573 treatment of, 573 diseases of, 570 ectopic, 570 gumma of, 574 operations on, 585 resection of, 585 sarcoma of, 574 tumors of, 573 solid, 574 Lockjaw, 42. See Tetanus. Longitudinal fractures, 800 Lorenz's treatment of congenital disloca- tion of hip, 907 Lower extremity, bones of, fractures of, 852 of femur, fractures of, 802 of humerus, fracture of, 835 leg, fractures of, 800 Lumbar abscess, 789 hernia, 940 puncture in acute septic lepto- meningitis, 301 in operations on spine, 380 Lumpy jaw, 08 Lung, abscess of, 470 prognosis of, 471 symptoms of, 470 treatment of, 470 actinomycosis of, 472 symptoms of, 472 1008 INDEX Lung, actinomycosis of, treatment of, 472 carcinoma of, 474 decortication of, 481 diseases of, 470 echinococcus cysts of, 475 prognosis of, 475 symptoms of, 475 treatment of, 475 emphysema of, 473 gangrene of, 472 prognosis of, 472 symptoms of, 472 treatment of, 472 gummatous infiltration of, 474 sarcoma of, 474 syphilis of, 474 tuberculosis of, 473 tumors of, 474 symptoms of, 474 treatment of, 475 Lupus, destruction of nose and, 424 of skin, 232 Luxatio erecta, 884 Lymph channels, diseases of, 228 injuries of, 278 treatment of, 278 obstruction of, 282 Filaria sanguinis hominis in, 282 nodes, carcinoma of, 293 cervical, tuberculosis of, 285 anemia in, 286 • edema in, 286 fever in, 286 prognosis of, 287 skin in, 286 symptoms of, 286 treatment of, 288 surgical, 288 diseases of, 278 hyperplasia of, 291 inflammation of, 281 sarcoma of, 293 syphilis of, 290 tuberculosis of, 284 Lymphadenitis, 281 chronic, 291 Lymphadenoma, 291 Lymphangioma, 85, 284 cavernous, 85 of jaws, 436 of mouth, 436 of pharynx, 436 Lymphangitis, 281 pancreatic, 592 symptoms of, 281 treatment of, 282 Lymphatic dilatation, 284 treatment of, 284 leukemia, 293 nevi, 85, 284 obstruction, maerocheilia and, 284 macrodactylia and, 284 Lymphatic obstruction, macroglossia and, 284 system, diseases of, 278 injuries of, 278 telangiectasis, 85 Lymphedema, 282 Lymphosarcoma, 82, 293 of rectum, 732 of spleen, 599 Lysins, 29 M McBurney's hook, 240 in reduction of dislocation of shoulder, 888 method of amputation at hip-joints, 958 operation for appendicitis, 564 point in appendicitis, 560, 562 Mackenzie's tonsillotome, 430 Maerocheilia, lymphatic obstruction and, 284 Macrodactylia, lymphatic obstruction and, 284 Macroglossia, lymphatic obstruction and, 284 Macular syphilide, 62 Madura foot, 228 Main-en-trident, 756 Malar bone, fractures of, 821 Malformations of breast, 483 congenital, of anus, 723 of rectum, 723 of urethra, 672 Malignant edema, 48 pustule, 47, 391 Mammary gland, diseases of, 483 inflammation of, 483 Manubrium sterni, dislocations of, 882 Many-tailed bandage, 139 Marine sponges, 132 Mastitis, acute, 483 symptoms of, 483 treatment of, 484 adolescentium, 484 chronic, 484 cystic, 488 interstitial, 485 treatment of, 485 neonatorum, 484 subacute, 485 Mastoiditis, 458 treatment of, 458 Mathew's operation for enucleation of tonsils, 430 Mattress suture, 145, 146 Maunsel's method of enterorrhaphy, 556 Maxilla, superior, fractures of, 822 symptoms of, 822 treatment of, 822 Maxillary antrum, empyema of, 42(> inflammation of, 426 treatment of, 426 INDEX 1009 Mayo's operations for umbilical hernia, 937 varicose vein enucleator, 266 Meckel's diverticulum, 547 Mediastinal cellulitis, acute, 475 symptoms of, 475 treatment of, 476 thoracotomy, 481 Mediastinum, carcinoma of, 476 cysts of, 476 diseases of, 475 fibroma of, 476 inflammation of, 475 lipoma of, 476 sarcoma of, 476 tumors of, 476 symptoms of, 476 treatment of, 477 Mediocarpal articulation, dislocation of, 893 Mediotarsal dislocation, 907 diagnosis of, 908 treatment of, 908 Medulla oblongata, lesions of, 349 Medullary carcinoma of rectum, 731 sarcoma of bone, 761 Melanosarcoma, 84 Melena, definition of, 123 Membranes of brain, contusions of, 356 inflammation of, 359 laceration of, 356 Meningitis, 359 cerebrospinal, 360 Meningocele, 365, 385 treatment of, 366 Meningomyelocele, 385 Mercier's coude catheter, 148 Metacarpal bones, fractures of, 850 diagnosis of, 850 treatment of, 851 Metacarpophalangeal joints, suppura- tive arthritis of, 211 Metallic catheter, 148 Metatarsal bones, dislocation of, 907 diagnosis of, 908 treatment of, 908 fractures of, 871 Metatarsalgia, anterior, 980 treatment of, 980 Metatarsophalangeal joints, amputation at, 963 Midbrain, lesions of, 348 Mid-palmar space, infection of, treat- ment of, 227 Miliary aneurism, 249 Miner's elbow, 302 Mirault's chiloplasty operation, 418 Moebius' sign in exophthalmic goitre, 406 Mole, hydatiform, 95 vesicular, 95 Moles of skin, 237 Moore's dressing for fractures of clavicle, 828 64 shuing Morbus coxa>, 794 Morton's painful joint, 980 Moschowitz on mechanism of hernia, 940, 941 operation for prolapse of rectum, 739 Motor area of brain, 346 Mouth, angioma of, 436 bacteria of, 21 cysts of, 434 treatment of, 434 diseases of, 431 epithelioma of, 434 floor of, von Langenbeck's opera- tion for removal of, 438 lipoma of, 436 lymphangioma of, 436 operations on, 437 osteoma of, 436 papilloma of, 436 tumors of, 434 Movable kidney, 606 Mucous cysts, 97 Mumps, 433 Murphy button, 555 anastomosis by, 555 drip, 186 Muscles, atrophy of, 297 contusions of, 294 diseases of, 296 fibroma of, 297 hernia of, 295 diagnosis of, 295 treatment of, 295 inflammation of, 296 injuries of, 294 new growths of, 297 rupture of, 294 diagnosis of, 294 treatment of, 294 syphilis of, 297 tuberculosis of, 297 tumors of, 297 wounds of, 295 Muscular weakness, fractures and, 812 Mycetoma of skin, 228 Myelocele, 385 prognosis of, 385 treatment of, 385 . Myeloma, 80 of bone, 762 Myoma, 85 heart, 121 Myositis, 296 acute primary, 296 ossificans, 297 Myxedema, operative, 412 Myxoma, 78 of breast, intracanalicular, 490 of intestine, 550 of kidney, 627 of nerves, 315 of rectum, 730 of spinal cord, 383 Myxosarcoma of breast, 491 1010 INDEX N Nail, 199 base of, 199 bed, 201 body of, 199 lunula of, 200 matrix of, 200 Nasal bones, fractures of, 820 Adams' forceps in, 821 symptoms of, 821 treatment of, 821 polypus, 428 treatment of, 428 Nasopharyngeal polypus, 428 symptoms of, 428 treatment of, 428 Nasopharynx, diseases of, 422 tumors of, 428 Neck, actinomycosis of, 69 carbuncle of, 391 treatment of, 391 cellulitis of, 389 deep, 389 symptoms of, 389 treatment of, 389 contusions of, 387 dermoids of, 392 diseases of, 388 erysipelas of, 389 of femur, fractures of, 852 of humerus, anatomic, fracture of, 831 surgical, fracture of, 831 hygromata of, 394 inflammation of, 388 injuries of, 387 lipoma of, 396 sarcoma of, 398 treatment of, 398 of scapula, fracture of, 827 tumors of, 392 wounds of, 387 Necrosis of bone, 753 Nephrectomy, 642 for tuberculosis of kidney, 621 Nephritis, surgical treatment of, 630 Nephrolithotomy, 640 Nephropexy, 642 Nephrotomy, 641 in renal calculus, 627 Nerves, anastomosis of, 318 in brachial paralysis, 320 in facial paralysis, 318 in infantile paralysis, 323 brachial, paralysis of, 320 operations for, 320 cervical sympathetic, resection of, for exophthalmic goitre, 318 for glaucoma, 318 contusions of, 303 symptoms of, 303 treatment of, 303 Nerves, diseases of, 307 facial, paralysis of, 318 operations for, 318 fibroma of, 315 fibroneuroma of, 315 fifth, neurectomy of first division of, 309 of second division of, 310 of third division of, 310 hernia and, 910 inflammation of, 307. See Neuritis, injuries of, 303 myxoma of, 315 operations on, 318 sarcoma of, 315 stretching of, in neuralgia, 309 in sciatica, 309 tumors of, 315 treatment of, 315 Nerve trunks, compression of, 306 symptoms of, 306 treatment of, 306 wounds of, 303 anesthesia in, 304 hyperemia in, 304 skin in, 304 suturing of, 305 symptoms of, 304 treatment of, 304 Neuralgia, 307 diagnosis of, 308 etiology of, 308 nerve stretching in, 309 neurectomy in, 309 neurotomy in, 309 removal of Gasserian ganglion in, 311 syphilis and, 308 treatment of, 308 injection methods in, 311 Neurasthenia, diagnosis of, from con- cussion of spinal cord, 380 Neurectomy of first division of fifth nerve, 309 intracranial, 311 in neuralgia, 309 of second division of fifth nerve, 310 of third division of fifth nerve, 310 Neuritis, 307 multiple, 307 optic, in tumors of brain, 368 symptoms of, 307 treatment of, 307 Neuroma, 86 of brain, 368 Neuropathic arthropathy, 801 Neurotomy in neuralgia, 309 Nevi, 84 lymphatic, 85 Nevolipoma, 267 Nevus, 267 skin in, 267 treatment of, 267 New growths. See Tumors. INDEX 1011 Nipple, Paget's disease of, 90, 487 treatment of, 487 Nitrous oxide as general anesthetic, 154 Nodular goitre, 400 Noma, 57, 431 Normal salt solution, intravenous infu- sion of, 151 Nose, bleeding from, 425. See Epis- taxis. destruction of, 424 complete, 424 lupus and, 424 operation for, 424 partial, 424 rhinoplasty in, 424 syphilis and, 424 trauma and, 424 diseases of, 422 epithelioma of, 431 foreign bodies in, 425 papilloma of, 431 sarcoma of, 431 tumors of, 428 Novocaine in local anesthesia, 169 Nystagmus in tumors of brain, 369 Obliterative arteritis, 248 Obstructed hernia, 914 Obstruction of bowel, 550 of lymph channels, 282 of meter, 633 Obturator artery, hernia and, 911 hernia, 940 Occipital artery, ligation of, 271 Odontoma, 80 of jaws, 436 Odontome, composite, 436 fibrous, 436 follicular, 436 radicular, 436 O'Dwyer's intubation instruments, 453 (Esophagus. See Esophagus. Oidii, 72 Oidiomycosis, 72 Oldhausen's method in treatment of congenital umbilical hernia, 935 Olecranon, fractures of, 840 diagnosis of, 840 treatment of, 840 Olfactory area of brain, 348 Olive-pointed bougie, 684 Operations for acute osteomyelitis, 745 for aneurism, 254 backache following, treatment of, 179 on brain, 371 for carcinoma of breast, 497 of prostate gland, 721 for cellulitis, 196 for cleft palate, 420 for destruction of nose, 424 Operations, discomfort following, treat- ment of, 178 for. empyema, Estlander's, 479 Fowler's, 481 Friedrich's, 480 osteoplastic, 480 Schede's, 479 on epididymis, 716 on esophagus, 449 for exophthalmic goitre, 406 for femoral hernia, 932 on gall-bladder, 585 on gall-ducts, 585 gas pains following, treatment of, 179 on genital organs, 716 for hare-lip, 417 headache following, treatment of, 179 for ingrowing toe-nail, 207 for inguinal hernia, 924 for injuries of spine, 383 on intestines, 553 on jaws, 437 on kidney, 638 on larynx, 449 for lingual goitre, 410 on liver, 585 on mouth, 437 nausea following, treatment of, 180 on nerves, 318 pain following, treatment of, 179 for paralysis of brachial nerves, 320 of facial nerves, 318 on penis, 716 on pericardium, 243 on pharynx, 437, 449 for piles, 737 for Pott's disease, 792 preparation of dressings for, 131 of instruments for, 130 of ligatures for, 130 of nurse for, 130 of operator for, 130 of patient for, 129 of room for, 132 of silk for, 130 of silkworm gut for, 130 of silver wire for, 130 of sponges for, 131 of sutures for, 130 for prolapse of rectum, 739 on prostate gland, 716 restlessness following, treatment of, 180 for s imple goitre, 403 sleeplessness following, treatment of, 180 for sliding hernia, 942 on spine, 386 on stomach, 534 for strangulated hernia, 920 for tenosynovitis, 223 thirst following, treatment of, 180 1012 INDEX Operations on thorax, 477 on tongue, 437 for tuberculosis of hip, 795 of joints, 787 of knee, 797 of lymph nodes, 288 for umbilical hernia, 937 on ureter, 638 for vesical calculus, 660 vomiting following, treatment of, 180 for wounds of heart, 246 Opsonins, 29 Optic thalamus, lesions of, 348 Orchitis, 702 symptoms of, 702 syphilitic, 703 treatment of, 702 Orcho-epididymitis, 702 Osteitis, 741 deformans, 754 symptoms of, 755 treatment of, 755 Osteo-arthritis, hypertrophic, 777 Osteo-arthropathy, pulmonary, 802 Osteochondritis in infants, 783 syphilitic, 750 Osteochondrosis, syphilitic, 68 Osteogenesis imperfecta, 756 Osteoma, 80 of bone, 758 of chest-wall, 463 of jaws, 436 of joints, 803 of mouth, 436 of pharynx, 436 Osteomalacia, 756 symptoms of, 756 ■ treatment of, 756 Osteomyelitis, 341 acute, 341, 741 colon bacillus and, 741 edema in, 743 fever in, 742 operations for, 745 pain in, 742 spontaneous, 341 etiology of, 341 pathology of, 341 symptoms of, 341 treatment of, 342 Staphylococcus pyogenes au- reus and, 741 streptococcus and, 741 symptoms of, 742 treatment of, 743 typhoid bacillus and, 741 x-rays in, 745 albuminosa, 749 treatment of, 749 chronic, 342, 748 pathology of, 342 symptoms of, 342 treatment of, 343 Osteomyelitis of distal phalanx, abscess of distal anterior closed space with, 210 idiopathic, 741 of jaws, 433 non-traumatic, 741 of ribs, 463 subacute, 748 cortical, of septic origin, 749 symptoms of, 749 treatment of, 749 suppurative, 749 syphilitic, 749 traumatic, 342, 741 pathology of, 342 symptoms of, 342 treatment of, 342 tuberculous, 343, 751 pathology of, 343 symptoms of, 343 treatment of, 343 typhoid, 749 symptoms of, 749 treatment of, 749 Osteoplastic craniotomy, 372 method of amputation of thigh, 960 operation for empyema, 480 thoracoplasty, 480 Osteotomy in congenital dislocation of hip, 968 Ostitis fibrosa, 760 Otis-Wyeth urethrotome, 686 Otitis media, 457 symptoms of, 457 treatment of, 458 Ovarian dermoid cysts, 99 Pachymeningitis, acute external, 359 chronic internal, 360 Paget's disease of bone, 754 of nipple, 90, 487 Palate, adenoma of, 436 cleft, 415 Brophy's operation for, 420 Lane's operation for, 421 Langenbeck's operation for, 421 epithelioma of, 434 gummatous infiltration of, 436 sarcoma of, 435 Palsies, traumatic, 306 Palsy, infantile cerebral, 367 Pancreas, carcinoma of, 593 diagnosis of, 593 symptoms of, 593 treatment of, 594 cyst-adenoma of, 594 cystic degeneration of, 595 cysts of, 594 hemorrhagic, 594 hydatid, 594 pseudo, 594 INDEX 1013 Pancreas, cysts of, retention, 594 treatment of, 595 true, 594 diseases of, 588 inflammation of, 588 sarcoma of, 594 tumors of, 593 Pancreatic apoplexy, 589 calculus, 595 symptoms of, 595 treatment of, 595 lymphangitis, 592 Pancreatitis, 588 acute, 589 abdomen in, 590 dyspnea in, 590 fever in, 590 leukocytosis in, 590 pain in, 590 * prognosis of, 591 symptoms of, 590 treatment of, 590 vomiting in, 590 chronic, 592 diagnosis of, 593 jaundice in, 592 symptoms of, 592 treatment of, 593 gangrenous, 589 hemorrhagic, 589 subacute, 591 anorexia in, 591 jaundice in, 591 nausea in, 591 pain in, 591 suppurative, 589 Papilloma, 86 of bladder, 665 duct, 87 of intestine, 551 of jaws, 436 of kidney, 627 of larynx, 446 of mouth, 436 of nose, 431 of penis, 692 of pharynx, 436 of rectum, 730 of scrotum, 692 of skin, 235 of trachea, 448 of ureter, 637 of urethra, 687 villous, 87 Papular syphilide, 62 Paracentesis, 477 pericardii, 243 Paralysis in acute septic leptomeningitis, 361 in aneurism, 252 of bladder, 671 of brachial nerves, 320 operations for, 320 in compression of brain, 355 Paralysis, congenital spastic, 367 in crushing of spinal cord, 381 in extradural hemorrhage, 357 of facial nerves, 318 operations for, 318 fractures and, 812 in hematoinyelia, 380 infantile, 323 in neuritis, 307 in simple goitre, 402 in tumors of spinal cord, 383 Paraphimosis of penis, 691 Parasitic cysts, 98 Parasyphilitic affections, 65 Parathyreopriva, 413 Parathyroid glands, 412 Paronychia, 204 treatment of, 204 Paronychium, 199 Parotid gland, abscess of, 390 treatment of, 391 carcinoma of, 398 epithelioma of, 398 inflammation of, 390 treatment of, 391 Patella, dislocations of, 900 diagnosis of, 901 inward, 901 outward, 901 by rotation, 901 treatment of, 901 fractures of, 864 diagnosis of, 864 prognosis of, 866 treatment of, 864 Patent urachus, 647 Pelvic outlet, hernia of, 939 Pelvis, fractures of, 825 diagnosis of, 825 treatment of, 826 Penis, cellulitis of, 688 chancre of, 690 chancroid of, 689 treatment of, 689 contusions of, 688 endothelioma of, 693 epithelioma of, 692 inflammation of, 688 operations on, 716 papilloma of, 692 paraphimosis of, 691 phimosis of, 690 circumcision in, 690 treatment of, 690 sarcoma of, 692 tumors of, 692 warts of, 692 wounds of, 688 Perforating ulcer of foot, 317 Perforation in duodenal ulcer, 526 in gastric ulcer, 523 Perforative appendicitis, acute, 560 Pericardial thoracolysis, 244 Pericardiolysis, 244 1014 INDEX Pericardiotomy, 243 for evacuation of a purulent exudate, 243 Pericarditis, suppurative, 242 tuberculous, 242 treatment of, 242 Pericardium, abscess of, 242 aspiration of, 243 diseases of, 241 foreign bodies in, 241 incision of, 243 inflammatory exudate in, 241 injuries of, 241 operation on, 243 puncture of, 243 serous effusions of, 241 treatment of, 242 wounds of, 241 Perineal dislocations of hip, 899 hypospadia, 672 prostatectomy, 719 Perinephritic abscess, 616 symptoms of, 616 treatment of, 617 Periosteal sarcoma of bone, 761 Periostitis, 741 Peripheral sarcoma of bone, 761 Periproctitis, 724 symptoms of, 724 treatment of, 725 Peripyloritis, 530 symptoms of, 530 treatment of, 530 Peritoneum, absorptive power of, 508 actinomycosis of, 518 diseases of, 508 inflammation of, 509 reparative power of, 508 Peritonitis, acute, 509 infective, 510 non-infective, 509 chronic, 518 diffuse, 511 after-treatment of, 516 complications of, 514 course of, 514 cyanosis in, 513 diagnosis of, 513 fever in, 513 hiccough in, 513 leukocytosis in, 513 meteorism in, 513 pain in, 512 prognosis of, 514 pulse in, 512 subphrenic abscess in, 514 fluid in, 515 symptoms of, 515 treatment of, 515 symptoms of, 511 tenderness in, 512 treatment of, 515 tumor in, 513 vomiting in,' 512 Peritonitis, generalized, 514 pneumococcus, 514 tuberculous, 516 ascitic, 516 caseating, 516 diagnosis of, 517 symptoms of, 516 treatment of, 517 Peritonsillar ahscess, 432 treatment of, 432 Pernicious anemia, 598 Peroneal artery, ligation of, 277 Pes cavus, 974 planus, 974 Petit's tourniquet, 254 Phagedenic chancroid, 689 ulcers of skin, 231 Phagocytosis in acute inflammation, 32 Phalanges of foot, dislocations of, 908 fractures of, 871 of hand, dislocation of, 895, 896 fractures of, 851 treatment of, 851 Pharyngotomy, Cheever's lateral, 439 subhyoid, 456 Pharynx, angioma of, 436 bacteria of, 21 diseases of, 431 epithelioma of, 448 gummatous infiltration of, 436 lipoma of, 436 lymphangioma of, 436 operations on, 437, 449 osteoma of, 436 papilloma of, 436 removal of, 439 sarcoma of 449 tumors of, 434, 448 diagnosis of, 448 treatment of, 448 wounds of, 388 Phelps' hip splint, 859 Phenolsulphonephthalein test in exami- nation of urine, 638 Phimosis of penis, 690 Phlebitis, 260 diagnosis of, 260 infective, 260 non-suppurative, 260 plastic, 260 suppurative, 260 treatment of, 261 Phlegmonous erysipelas, 41 Phloridzin test in examination of urine, 638 Phosphate calculi, 657 Pia arachnoid, anatomy of, 335 mater, inflammation of, 360 Pial hemorrhage, 358 Piles, 735. See also Hemorrhoids, diagnosis of, 736 external, 735 inflamed, 735 internal, 735 INDEX 101. Piles, mixed, 735 operations for, 737 pain in, 735 removal of, 737 symptoms of, 735 thrombotic, 735 treatment of, 736 radical, 736 Pirogoff's operation for amputation at ankle-joint, 961 Plaster jacket in Putt's disease, 790 Plaster-of- Paris bandage, 141' Pleura, diseases of, 46 I endothelioma of, 474 tumors of, 474 Pleurosthotonus in tetanus, 44 Pneumatic proctosigmoidoscope, 727 Pneumectomy, 481 Pneumococcus in infective arthritis, 774 in peritonitis, 514 Pneumonia, postoperative, 176 prophylaxis in, 176 treatment of, 177 Pneumothorax. 464 artificial. 477 avoidance of, in operations on lung, 481 on mediastinal organs, 481 closed, 464 open, 464 symptoms of, 464 treatment of, 464 wounds of chest-wall and, 460 Polyarthritis, chronic primary progres- sive, 776 Polycystic kidney, 629 Polydactylism, 981 Polvp, fungoid pedunculated, of urethra, 687 Polyps of rectum, 730 Polypus, fibrous, 428 nasal, 428 nasopharyngeal, 428 Polyuria in tuberculosis of kidney, 619 Pons, lesions of, 348 Pool's phenomena in tetany, 413 Popliteal artery, ligation of, 276 "Port-wine marks," 267 Portal thrombosis, appendicitis and, 568 Posterior tibial artery, ligation of, 276 Postoperative conditions, treatment of, 174 hemorrhages, 175 pneumonia, 176 pulmonarv embolism, treatment of, 187 renal complications, 177 thrombosis, treatment of, 187 Postrectal dermoids, 730 Pott's disease, 788 abscess in, 789 Bradford frame in, 791 kyphosis in, 789 operation for, 792 Pott's disease, pain in, 789 paralysis in, 790 plaster jacket in, 790 symptoms of, 789 Taylor brace in, 791, 792 treatment of, 791 fracture, 867 Dupuytren's splint in, 869 treatment of, 869 Precentral area of brain, 346 Precipitins, 29 Presenile gangrene 54 Proctitis, 724 symptoms of, 724 treatment of, 724 Proctoscope, Kelly's, 727 Proctosigmoidoscope, pneumatic, 727 Prolapse of brain, 366 of rectum, 738 of ureter, 632 Prolapsus ani, 739 recti, 739 Preperitoneal hernia, 930 Prostate gland, carcinoma of, 715 operation for, 72 1 prognosis of, 716 symptoms of. 715 treatment of, 716 diseases of, 708 exposure of, 717 inflammation of, 708 operation on, 716 sarcoma of, 716 senile hypertrophy of, 710 catheterism in, 713 diagnosis of, 712 prostatectomy in, 714 symptoms of, 711 treatment of, 713 urine in, 712 tuberculosis of, 710 symptoms of, 710 treatment of, 710 tumors of, 715 Prostatectomy, 71s perineal, 119 in senile hypertrophy of prostate glands, 714 suprapubic, 718 Prostatic calculi, 710 catheter, 148 Prostatitis, acute, 708 diagnosis of, 708 symptoms of, 709 treatment of, 709 chronic, 710 symptoms of, 710 treatment of, 710 diffuse, 708 follicular, 708 suppurative, 708 Prostatopelvic carcinosis, 715 Proximal closed space, abscess of, 212 Pruritus ani, 729 1010 INDEX Pruritus ani, treatment of, 730 Psammoma, 96 of spinal cord, 383 Pseudo-arthritis, fractures and, 812 Pseudohermaphrodism, 072 Psoas abscess, 789 diagnosis of, from femoral hernia, 932 Pubic dislocations of hip, 879 Pulmonary embolism, postoperative, treatment of, 187 emphysema, 473 osteo-arthropathy, 802 Pulsating angioma, 252 Punch fractures, 850 Puncture of pericardium, 243 Pus, definition of, 35 Pustulocrustaceous syphilides, 64 Pyelitis, 613 symptoms of, 613 treatment of, 614 Pyelonephritis, 613 suppurative, 614 treatment of, 615 Pyelotomy, 641 Pyemia, definition of, 38 Pylorectomy, 535 Pyloric stenosis, 527 Boas-Oppler bacillus in, 529 diagnosis of, 528 symptoms of, 527 treatment of, 529 Pyloroplasty, 535 Finney's operation, 535 Pylorus, dilatation of, 535 Pyogenic organisms in acute inflamma- tion, 32 Pyonephrosis, 615, 633 symptoms of, 615 treatment of, 615 Pyorrhea alveolaris, inflammation of joints and, 771 Pyothorax, 465 symptoms of, 466 treatment of, 466 Pyuria in renal calculus, 623 in vesical calculus, 659 Rachitic rosary, 757 Rachitis, 756 constipation in, 757 diarrhea in, 757 flatulence in, 757 symptoms of, 757 treatment of, 758 Racket-shaped method of amputation, 951 Radial artery, ligation of, 273 bursa, extension of infection from, 221 Radicular odontome, 436 Radiocarpal articulation, dislocations of, 893 Radio-ulnar articulation, inferior, dislo- cations of, 892 Ratlins, dislocations of, 890 shaft of, fractures of, 842 complications of, 842 diagnosis of, 842 treatment of, 843 subluxation of, 891 upper extremity of, fractures of, 841 diagnosis of, 841 treatment of, 841 Ranula, 434 Raynaud's disease, gangrene from, 55 Rectum, adenoma of, 730 angioma of, 730 carcinoma of, 731 diagnosis of, 732 medullary, 731 scirrhus, 731 symptoms of, 731 treatment of, 732 congenital malformations of, 723 stricture of, 723 treatment of, 723 dermoids of, 730 treatment of, 731 diseases of, 723 epithelioma of, 731 fibroma of, 730 inflammation of, 724 injuries of, 723 lipoma of, 730 lymphosarcoma of, 732 myxoma of, 730 papilloma of, 730 polyps of, 730 prolapse of, 738 diagnosis of, 739 operations for, 739 Moschowitz's, 739 Whitehead's, 739 sigmoidopexy for, 739 treatment of, 739 sarcoma of, 732 diagnosis of, 732 treatment of, 732 stricture of, 726 fibrous, 726 inflammatory, 726 symptoms of, 726 treatment of, 727 tumors of, benign, 730 malignant, 731 treatment of, 732 ulcers of, 728 actinomycotic, 729 chancroidal, 728 non-specific, 728 simple, 728 symptoms of, 729 syphilitic, 728 treatment of, 729 INDEX 1017 Rectum, ulcers of, tuberculous, 728 wounds of, 723 Recurrent bandage, 136 Reducible hernia, 913 Reef knot, 144 Reichman's disease, 52S Relapsing fever, chronic, 291 Renal artery, aneurism of, 605 hematuria in, 605 symptoms of, 605 treatment of, 606 tumor in, 605 anomalies of, 600 calculus, 622 causes of, 622 diagnosis of, 625 hematmia in, 623 nephrotomy in, 626 pain in, 623 pathology of, 622 prognosis of, 626 pyelotomy in, 626 pyuria in, 623 symptoms of, 623 treatment of, 626 .r-rays in, 624, 625 complications, postoperative, 177 treatment of , 178 suppuration, 608 ascending, 608 acute, 610 diagnosis of, 610 hematogenous, 609 prognosis of, 611 treatment of, 611 Resection of cervical sympathetic nerves for exophthalmic goitre, 318 for glaucoma, 318 in exophthalmic goitre, 410 of liver, 585 of ribs for empyema, 479 in simple goitre, 404 Respiratory anthrax, 48 passages, bacteria of, 21 Retention cysts, 97 of pancreas, 594 of urine, 670 Retropharyngeal abscess, 432, 789 treatment of, 433 Reverdin's methods of skin-grafting, 239 Rhabdomyoma, 85 Rheumatism, chronic, 777 Rheumatoid arthritis, 777 Rhinophyma, 428 treatment of, 428 Rhinoplasty in destruction of nose, 424 Ribs, dislocation of, 883 fractures of, 824 diagnosis of, 824 prognosis of, 824 treatment of, 824 osteomyelitis of, 463 treatment of, 463 Ribs, resection of, for empyema, 479 Rickets, congenital, 756 Risus sardonirus, 1 1 Roberts' fracture, s 1 I Rodent ulcer, 93 of skin, 233 Roller bandage, 134 Roseola, syphilitic, 62 Round-celled sarcoma, 82 Roux's operation for amputation at ankle-joint, 962 Rubber drainage tube, 143 Rupial syphilides, 64 Rupture of aneurism, 251, 252 of bladder, 648 of kidney, 603 of muscles, 294 of tendons, 294 of urethra, 674 S Sacculated aneurism, 249 Sacro-iliac disease, 801 symptoms of, 801 treatment of, 801 Saddle-nose, 422 treatment of, 422 Salivary glands, inflammation of, 433 tumors of, 398 Salt solution, intravenous infusion of, 151 Salvarsan in syphilis, 65 Saphenous varix, diagnosis of, from femoral hernia, 932 Sarcoma, 81 of abdominal wall, 507 of adrenal gland, 629 of bladder, 665 of bone, 760 of brain, 368 of breast, 491 of chest-wall, 463, 464 giant-celled, 84 of gums, 435 of intestine, 551 of jaws, 435 of kidney, 628 of liver, 574 of lung, 474 of lymph nodes, 293 of mediastinum, 476 of neck, 398 of nerves, 315 of nose, 431 of palate, 435 of penis, 692 of pharynx, 449 of prostate gland, 716 of rectum, 732 round-celled, 82 of skin, 238 of spinal cord, 383 spindle-cell, 83 1018 INDEX Sarcoma of spleen, 599 of stomach, 533 of suprarenal gland, 629 of testicle, 705 of thyroid gland, 411 of tongue, 435 of tonsils, 435 of ureter, 637 Sarcomatous ulcers of skin, 234 Sayre's dressing for fractures of clavicle, 830 splint in tuberculosis of hip, 795 Scalds of skin, 189 Scalp, abscess of, 332 treatment of, 332 anatomy of, 324 ■ avulsion of, 330 treatment of, 330 burns of, 330 treatment of, 331 cellulitis of, 331 treatment of, 331 contusions of, 326 healing of, 327 hematoma in, 326 subcutaneous, 326 treatment of, 327 cysts of, dermoid, 334 pathology of, 334 symptoms of, 334 treatment of, 334 sebaceous, 333 pathology of, 333 symptoms of, 333 treatment of, 334 diseases of, 331 erysipelas of, 332 symptoms of, 332 treatment of, 332 furunculosis of, 331 treatment of, 331 inflammation of, 331 injuries of, 326 lipoma of, 333 pathology of, 333 symptoms of, 333 treatment of, 333 new growths of, 333 tumors of, 333 wounds of, 328 gunshot, treatment of, 329 incised, 328 lacerated, 328 punctured, 328 treatment of, 328 Scapula, fractures of, 826 of acromion process of, 826 diagnosis of, 827 treatment of, 827 of body of, 827 diagnosis of, 827 treatment of, 827 of coracoid process of, 828 diagnosis of, 828 Scapula, fractures of coracoid process of, treatment of, S2S of glenoid process of, 827 diagnosis of, 827 treatment of, 827 of neck of, 827 diagnosis of, 827 treatment of, 827 of spine of, 827 diagnosis of, 827 treatment of, 827 Schede's thoracoplasty, 479 Schlesinger's sign in tetany, 413 Sciatic artery, ligation of, 275 dislocations of hip, 897 Sciatica, nerve stretching in, 309 Scirrhus carcinoma, 90 of breast, 493 of rectum, 731 en cuirasse, 90 Sclerosis of bone, 753 Scoliosis, 964 symptoms of, 964 treatment of, 965 Scorbutic ulcers of skin, 231 Scrofuloderma, 287 Scrotum, cellulitis of, 688 contusions of, 688 cysts of, 692 epithelioma of, 693 treatment of, 693 inflammation of, 688 lipoma of, 692 papilloma of, 692 tumors of, 692 warts of, 692 wounds of, 688 Sebaceous cysts, 97 of chest-wall, 463 of scalp, 333 of scrotum, 692 of skin, 235 Semilunar bones, dislocations of, 893 treatment of, 893 cartilage, dislocation of, 770, 903 diagnosis of, 904 treatment of, 904 injury of, 770 Seminal vesicle, disease of, 706 exposure of, 717 inflammation of, 706 tuberculosis of, 707 symptoms of. 707 treatment of, 708 vesiculitis, 706 symptoms of, 706 treatment of, 707 x-rays in, 707 Senile gangrene, 53 Sepsis, acute general, 38 abscesses in, 39 albuminuria in, 39 chills in, 39 diarrhea in, 39 INDEX 1010 Sepsis, acute general, fever in, 39 leukocytosis in, 39 nausea in, 39 prognosis of, W.) skin in, '-'M symptoms of, 39 treatment of, 39 vomiting in, 39 Septic intoxication, 38 Septicemia, 38 Serous cysts, 97 Serpiginous syphilides, 64 Shaft of femur, fractures of, 859 of humerus, fracture of, 834 of radius, fractures of, 842 Shock, 101 alcoholism and, 104 anesthetic, treatment of, 168 in aneurism, 253 anoci-association in, 109 blood-pressure in, 102 in burns of skin, 189 diagnosis of, differential, 106 drugs in, 107 etiology of, 104 kinetic theory of, 103 morbid anatomy of, 103 prognosis of, 106 prophylaxis in, 108 • pulse in, 105 in rupture of bladder, 648 symptoms of, 105 treatment of, 106, 174 uremia and, 104 vomiting in, 105 in wounds of heart, 245 Shoulder, dislocations of, 883 causes of, 883 complications of, 885 diagnosis of, 885 old, reduction of, 888 reduction of, by extension, 885 Kocher's method, 886 McBurney's hook in, 888 subclavicular, 884 subcoracoid, 883 subglenoid, 884 subspinous, 884 supracoracoid, 885 symptoms of, 885 treatment of, 885 tuberculosis of, 799 excision in, 799 anterior method, 799 Kocher's method, 799 symptoms of, 799 treatment of, 799 Shoulder-joint, amputation at, 955 traumatic arthritis in, 772 tuberculous arthritis of, 799 Sigmoidopexy for prolapse of rectum, 739 Simon's chiloplasty operation, 418 Sinus, frontal, inflammation of, 427 Sinuses, accessory, diseases of, 422 Sinuses of brain, thrombosis of, 363 Skey's operation for amputation ;it ankle-joint, 96)5 Skin, abrasion of, 22 ( .l in acquired syphilis, 62 actinomycosis of, 72, 228 ainhum of, 229 atrophy of, in varicose veins, 264 bacteria of, 20 blastomycosis of, 228 boil of, 194 burns of, 189 symptoms of, 189 treatment of, 190 carcinoma of, 238 treatment of, 239 in cholelithiasis, 578 contusions of, 192 treatment of, 193 cysts of, 235 treatment of, 235 dermatitis of, x-ray, 193 treatment of, 194 diseases of, 193 in elephantiasis, 283 epithelioma of, 238 erysipelas of, 193 excoriation of, 229 fibroma of, 237 fibroneuromata of, 237 frambesia of, 228 furuncle of, 194 guinea-worm disease of, 228 inflammation of, 194 injuries of, 189 keloid of, 237 treatment of, 238 lupus of, 232 moles of, 237 mycetoma of, 228 in nevus, 267 new growths of, 235 papilloma of, 235 sarcoma of, 238 idiopathic multiple hemorrhagic, 239 treatment of, 239 scalds of, 189 syphilis of, 228 in tuberculosis of cervical lymph nodes, 286 tumors of, 235 ulcers of, 229 carcinomatous, 234 chronic, 231 circulatory, 230 epitheliomatous, 233 exuberant, 230 fungating, 230 healing, 230 indolent, 231 infective, 230 inflamed, 230 Marjolin's, 232 1020 INDEX Skin, ulcers of, phagedenic, 231 rodent, 233 sarcomatous, 234 scorbutic, 231 secondary malignant, 234 sloughing, 231 spreading, 231 syphilitic, 231 traumatic, 230 treatment of, 234 tuberculous, 231 warts of, 235 in wounds of nerve trunks, 304 Skin- and muscle-flap method of ampu- tations, 950 Skin-flap method of amputations, 949 Skin-grafting, 239 method of, Reverdin's, 239 Thiersch's, 239 Wolfe's, 240 Skull, anatomy of, 334 diseases of, 341 fractures of, 336 bending, 337 bursting, 337 circumscribed without displace- ment, 336 classification of, 336 hemorrhage in, 338 inner table alone, 336 outer table alone, 336 symptoms of, 338 treatment of, 340 injuries of, 336 osteoplastic resection of, 373 Sliding hernia, 940 Sling, 141 and chest binder, 141 Sloughing ulcers of skin, 231 Spastic paralysis, congenital, 367 Spermatic cord, dilated, 693 hydrocele of, 697 torsion of, 700 Spheroidal carcinoma, 87, 90 Spica bandage, 134 Spina bifida, 384 occulata, 385 Spinal anesthesia, 170 cord, anatomy of, 374 chondroma of, 383 concussion of, 380 diagnosis of, from hysteria, 380 from neurasthenia, 380 contusion of, 380 crushing of, incomplete, 382 transverse, 381 prognosis of, 382 symptoms of, 381 treatment of, 382 diseases of, 374 endothelioma of, 383 exostoses of, 383 fibroma of, 383 Spinal cord, glioma of, 383 hemorrhage of, 380 extradural, 380 intramedullary, 380 punctate, 380 subdural, 380 injuries of, 374 lipoma of, 383 myxoma of, 383 psammoma of, 383 sarcoma of, 383 syphilis of, 383 tuberculosis of, 383 tumors of, 383 prognosis of, 384 symptoms of, 383 treatment of, 384 hemorrhage, 380 Spindle-cell sarcoma, 83 Spine, atlas of fracture of, 378 axis of, fracture of, 378 concussion of, 380 diseases of, 374 dislocations of, 879 bilateral, 880 diagnosis of, 880 manipulation of, 881 prognosis of, 881 treatment of, 881 unilateral, 880 fracture-dislocation of, 377, 880 fractures of, 374 laminectomy in, 379 symptoms of, 377 treatment of, 378 injuries of, 374 operation for, 383 lateral curvature of, 964 symptoms of, 964 treatment of, 964 operations on, 386 laminectomy in, 386 lumbar puncture in, 386 of scapula, fracture of, 827 Spiral fractures, 806 reversed bandage, 134 Spirocheta pallida in syphilis, 61 Spleen, abscess of, 596 symptoms of, 596 treatment of, 597 absence of, 596 accessory, 596 carcinoma of, 599 cavernous angioma of, 599 cirrhosis of, hypertrophic, 599 congenital anomalies of, 596 cysts of, 599 ectopic, 596 diagnosis of, 596 splenectomy for, 596 symptoms of, 596 * treatment of, 596 endothelioma of, 599 INDEX 1021 Spleen, enlargement of, 597. See Splenomegaly, fibroma of, 599 lymphosarcoma of, 599 sarcoma of, 599 surgical diseases of, 596 tuberculosis of, 597 tumors of, 599 Splenectomy for ectopic spleen, 596 for splenomegaly, 598 Splenomegaly, 597 etiology of, 597 pathology of, 597 splenectomy for, 598 symptoms of, 598 treatment of, 598 Splints for fractures, 813 Spondylitis, tuberculous, 788 Spondylolisthesis, 965 * symptoms of, 966 Sprains of joints, 766 Squamous carcinoma, 87, 92 Staphylococcus in acute arthritis, 774 osteomyelitis and, 741 Staphylorrhaphy, 420 Status lymphaticus, 111 diagnosis of, 113 in infants, 112 in man, 112 morbid anatomy of, 112 operative deaths in, 113 symptoms of, 112 in women, 112 treatment of, 113 Steam autoclave, 132 Stellwag's sign in exophthalmic goitre, 406 Stenosis in duodenal ulcer, 526 pyloric, 527 Sterilizer, Arnold, 132 Sternal end of clavicle, dislocation of, 878 Sternum, dislocations of, 882 of body from manubrium, 882 symptoms of, 882 treatment of, 882 of ensiform process of, 882 symptoms of, 883 treatment of, 883 fractures of, 823 diagnosis of, 823 treatment of, 824 Still's disease, 777, 781 Stoke's method of amputation at knee- joint, 960 Stomach, bacteria of, 22 carcinoma of, 530 anemia in, 532 Boas-Oppler bacillus in, 532 colloid, 531 diagnosis of, 532 emaciation in, 531 hemorrhage in, 532 pain in, 531 Stomach, carcinoma of, prognosis of, 533 symptoms of, 531 treatment of, 533 vomiting in, 531 a;-rays in, 532 dilatation of, 519 diagnosis of, 520 symptoms of, 520 treatment of, 520 diseases of, 518 enteroliths in, 518 foreign bodies in, 518 symptoms of, 519 treatment of, 519 hairballs in, 518 hour-glass, 530 gastro-enterostomy in, 530 gastrogastrotomy in, 530 gastroplasty in, 530 treatment of, 530 operations on, 534 sarcoma of, 533 tuberculosis of, 546 symptoms of, 546 tumors of, 530 ulcer of, 521. See Gastric ulcer. Stomatitis, gangrenous, 431 prognosis of, 431 symptoms of, 431 treatment of, 431 Stovaine in local anesthesia, 171 Strangulated hernia, 914 Strangulation of bowel, 550 Streptococcus in acute infective arthritis, 774 osteomyelitis and, 741 Streptothrix actinomyces, 68 Stricture of esophagus, 444 of rectum, 726 congenital, 723 of urethra, 680 Struma, 399 Subacromial bursitis, 301 Subaponeurotic hematoma in contusions of scalp, 326 Subastragaloid dislocations, 906 backward, 906 diagnosis of, 906 inward, 906 outward, 907 treatment of, 907 Subclavian artery, ligation of, 271 Subclavicular dislocations of shoulder, 884 Subcoracoid dislocations of shoulder, 883 Subcutaneous abscess, 197 contusions of scalp, 326 Subcuticular suture, 146 Subdeltoid bursitis, 301 Subdural hemorrhage, 358, 380 Subglenoid dislocations of shoulder, 884 Subhyoid pharyngotomy, 456 Sublingual gland, carcinoma of, 398 epithelioma of, 398 1022 INDEX Subluxation of radius, 891 Submammary abscess, 484 Submaxillary gland, carcinoma of, 398 epithelioma of, 398 Subparietal injuries of kidney, 602 Subpectoral abscess of chest-wall, 462 Subperiosteal abscess, 742 hematoma in contusions of scalp, 326 Subphrenic abscess, appendicitis and, 568 in diffuse peritonitis, 514 Subpial hemorrhage, 358 Subspinous dislocations of shoulder, 884 Subungual space, 201 abscess of, 205 Supernumerary fingers, 981 Superficial femoral artery, ligation of, 275 Suppuration, 35 Suppurative cholecystitis, 580 osteomyelitis, 749 pancreatitis, 589 pericarditis, 242 phlebitis, 260 prostatitis, 708 pyelonephritis, 614 Supracoracoid dislocations of shoulder, 885 Supracotyloid dislocations of hip, 899 Suprapubic lithotomy in tumors of bladder, 666 hi vesical calculus, 661 prostatectomy, 718 Suprarenal gland, hypernephroma of, 629 sarcoma of, 629 tumors of, 627 struma, 630 Surgeon's knot, 144, 145 Surgical neck of humerus, fracture of, 831 technic, 128 Suture, chain-stitch, 145 continued, 145 interrupted, 145 mattress, 145, 146 subcuticular, 146 through-and-through, 146 Syme's operation for amputation at ankle-joint, 961 Sympathectomy in exophthalmic goitre, 407 Syncytioma, 95 Syndactylism, 980 Synovitis, chronic, 802 symptoms of, 802 treatment of, 802 Syphilide, macular, 62 papular, 62 pustulocrustaceous, 64 rupial, 64 serpiginous, 64 tubercular, 64 ulcerative, 64 Syphilis, 61 Syphilis, acquired, 61, 62 chancre, 62 diagnosis of, 65 initial lesion, 62 mercury in, 65 mucous patches in, 62 tubercles in, 64 primary, 62 salvarsan in, 65 secondary, 62 Spirocheta pallida in, 61 symptoms of, 62 tertiary, 64 treatment of, 65 Wassermann reaction in, 65 aneurism and, 249 of bone, 749 of breast, 485 congenital, 61, 66 Colles' law in, 66 pregnancy and, 66 symptoms of, 67 treatment of, 68 of cranial bones, 343 destruction of nose and, 424 of epididymis, 702 etiology of, 61 of joints, 782 of kidney, 617 of larynx, 448 of lung, 474 of lymph nodes, 290 of muscles, 297 neuralgia and, 308 of skin, 228 of spinal cord, 383 of testicle, 703 tumors of brain and, 370 Syphilitic arthritis, 782 dactylitis, 750 endarteritis, 65 epiphysitis, 783 osteochondritis, 750 osteochondrosis, 68 osteomyelitis, 749 roseola, 62 ulcers of rectum, 728 of skin, 231 Syringomyelocele, 385 Tachycardia in exophthalmic goitre, 406 Talipes calcaneovalgus, 973 calcaneus, 974 equinovarus, 973 equinus, 974 valgus, 974 varus, 973 Tamponade, heart, 245 Tarsal bones, dislocations of, 907 diagnosis of, 908 INDEX 1023 Tarsal hones, dislocations of, treatment of, 908 tuberculosis of, 799 Tarsometatarsal joint, disarticulation of, 963 Taxis in strangulated hernia, 919 Taylor brace in Pott's disease, 791, 792 splint in tuberculosis of hip, 79.5 T-bandage, 139 Teale's method of amputation, 950 Telangiectasis, lymphatic, 85 Telangiectodes angioma, 85 Temporal artery, ligation of, 271 Tendons, diseases of, 297 dislocation of, 296 diagnosis of, 296 treatment of, 296 extensor, 202 inflammation of, 297 injuries of, 294 rupture of, 294 diagnosis of, 294 treatment of, 294 sheaths, extensor, 221 infection of, 215 diagnosis of, 222 relation of, to thenar and mid-palmar spaces, 220 secondary extension of, 221 tumor of, 298" wounds of, 295 treatment of, 296 Tenosynovitis, 222, 297 operations for, 223 Teratoma, 94 of testicle, 705 Terminal infection, 28 Testicle, adenoma of, 705 carcinoma of, 705 contusions of, 700 symptoms of, 700 treatment of, 700 diseases of, 699 ectopic, 699 treatment of, 699 epithelioma of, 705 fibrocystic disease of, 705 hernia of, 700 inflammation of, 702 injuries of, 699 sarcoma of, 705 syphilis of, 703 diagnosis of, 703 treatment of, 703 Wassermann reaction in, 703 teratoma of, 705 tuberculosis of, 703 diagnosis of, 704 treatment of, 704 tumors of, 705 diagnosis of, 705 mixed, 705 prognosis of, 706 treatment of, 706 Testicle, wounds of, 700 Tetania, 413 Tetanus, 42 acute, 44 cephalic, 44 chronic, 44 diagnosis of, 44 etiology of, 42 pathological anatomy of, 43 prognosis of. 44 symptoms of, 44 treatment of, 44 Tetany, 412 arm test in, 413 Chvostek's symptom in, 413 course of, 413 Erb's test in, 413 facial phenomena in, 413 leg phenomena in, 413 Pool's phenomena in, 413 Schlesinger's sign in, 413 treatment of, 414 Trousseau's phenomena in, 413 Thenar eminence, abscess of, 220 infection of, treatment of, 227 Thiersch's methods of skin-grafting, 239 Thigh, amputation of, 959 osteoplastic method of, 960 Thomas splint in tuberculosis of hip, 795 of knee, 797 Thompson searcher, 659 Thoracic aneurism, 251 Thoracolysis, pericardial, 244 Thoracoplasty, 479 Estlander's, 479 Friedrich's, 480 osteoplastic. 480 Schede's, 479 Thoracotomy, 477 mediastinal, 481 Thorax, actinomycosis of, 70 operations on, 477 Thrombosis, portal, appendicitis and, 568 postoperative, treatment of, 187 of sinuses of brain, 363 Thrombotic piles, 735 Through-and-through suture, 146 Thymectomy in exophthalmic goitre, 407 Thymus in exophthalmic goitre, 405 Thyrodermoids, 730 Thvroglossal cvsts, 393 fistula?, 393 Thyroid artery, inferior, ligation of, 272 superior, hgation of, 271 cartilage, complete section of, 449 dislocations of hip, 897 gland, anomalies of, 398 carcinoma of. 411 treatment of, 411 in exophthalmic goitre, 405 inflammation of, 411 symptoms of, 411 treatment of, 411 1024 INDEX Thyroid gland, sarcoma of, 411 treatment of, 411 in simple goitre, 400 tumors of, 411 lingual, 410 secretion, deficiency of, 412 treatment of, 412 Thyroidectomy in exophthalmic goitre, 407 Thyrotomy, 449 Thyrotoxicosis, 404 Tibia, fracture of, S66 Tibial arteries, ligation of, 276 Tibiotarsal dislocations, 905 backward, 905 forward, 905 outward, 906 symptoms of, 905 treatment of, 906 upward, 906 Tic convulsif, 315 douloureux, 309 Toe-nail, ingrowing, 206 Toes, amputation of, 963 Tongue, carcinoma of, 435 prognosis of, 435 symptoms of, 435 treatment of, 435 epithelioma of, 434 gummatous infiltration of, 436 ichthyosis of, 432 inflammation of, 432 leukoplakia of, 432 operations on, 437 removal of, 437 von Langenbeck's operation for, 438 sarcoma of, 435 tuberculous ulceration of, 437 Tonsillitis, 432 Tonsillotome, Mackenzie's, 430 Tonsils, enlarged, 430 treatment of, 430 enucleation of, 430 epithelioma of, 434 removal of, von Langenbeck's opera- tion for, 438 sarcoma of, 435 Torsion of spermatic cord, 700 Torticollis, 316 treatment of, 317 Tourniquet, Brewer's, in amputations, 945 Petit's, 254 Trabeculated bladder, 68, 71 1 Trachea, adenoma of, 448 chondroma of, 448 diseases of, 440 fibroma of, 448 foreign bodies in, 440 treatment of, 441 lipoma of, 448 papilloma of, 448 tumors of, 448 Trachea, wounds of, 388 Tracheal dilator, 450 tube, 450 Tracheotomy, 449 tube in position, 451 Trade bursitis, 302 Transduodenal choledochotomy, 587 Transfusion of blood, 149 cannula, Crile's, 149 Transverse fractures, 806 Trauma, destruction of nose and, 424 hernia and, 913 inflammation of joints and, 770 Traumatic aneurism, 249 fractures and, 812 cephalagia, 367 dermoids, 98 dislocations, 873 epilepsy, 366 gangrene, 55 hemorrhage, 122 osteomyelitis, 342, 741 palsies, 306 ulcers of skin, 230 Trendelenburg's sign in varicose veins, 264 Trephining, 371 Triangular bandage, 139 Trigger-finger, 981 treatment of, 981 Trigonitis, 650 Trochanters of femur, fractures of, 852 Tropocaine in local anesthesia, 171 Trousseau's phenomena in tetany, 413 Trunk, bone of, fractures of, 823 T-shaped fractures, 806 Tubercular syphilides, 64 Tuberculosis, 58 of ankle, 798 bacillus of, 58 of bladder, 655 of bone, 751 of breast, 486 of cervical lymph nodes, 285 of cranial bones, 343 diagnosis of, bacteriolgical, 60 biological, 61 of elbow, 800 examination of serous exudate in, 61 of sputum in, 60 of urine in, 61 of fascia?, 299 of hip, 794 ileocecal, 546 of intestine, 546 of joints, 783 of kidnej', 618 of knee, 796 of larynx, 448 of lung, 473 of lymph nodes, 284 modes of infection in, 60 of muscles, 297 predisposing factors in, 60 INDEX 1025 Tuberculosis of prostate gland, 710 of sacro-iliac joint, 801 of seminal vesicle, 707 of shoulder, 799 of spinal cord, 383 of spleen, 597 of stomach, 546 of tarsal bones, 799 of testicle, 703 tubercle in, 59 tumors of brain and, 370 of vertebral bodies, 788 of wrist, 800 Tuberculous arthritis, 785 of ankle-joint, 798 of hip-joint, 794 of knee-joint, 798 bone-abscess, 751 dactylitis, 751 osteomyelitis, 343, 751 pericarditis, 242 peritonitis, 516 sequestrum, 751 spondylitis, 788 ulceration of tongue, 437 ulcers of rectum, 728 of skin, 231 wart, 231 Tuberosities of humerus, fracture of, Tubulocyste, 100 Tumors, 74 of abdominal wall, 507 of adrenal gland, 629 in aneurism of renal artery, 605 of bladder, 664 of bloodvessels, 249 of bone, 758 of brain, 368 of breast, 489 of bursa?, 302 of chest-wall, 463 _ classification of, 77 connective-tissue, 77 epithelial tissue, 77 of esophagus, 448 etiologv of, 74 of face^ 392 of gall-bladder, 583 of gall-ducts, 584 innocence of, 75 of intestine, 550 of jaw, 434 of joints, 803 of kidney, 627 of larynx, 446 of liver, 573 of lung, 474 malignancy of, 75 of mediastinum, 476 of mouth, 434 of muscles, 297 of nasopharynx, 428 of neck, 392 of nerves, 315 Tumors of nose, 428 of pancreas, 593 of penis, 692 of pharynx, 434, 448 of pleura, 474 predisposing factors in, 75 of prostate gland, 715 of rectum, 730 of salivary glands, 398 of scalp, 333 of scrotum, 692 of skin, 235 of spinal cord, 383 of spleen, 599 of stomach, 530 of suprarenal gland, 627 of tendon sheaths, 298 of testicle, 705 of thyroid gland, 411 of trachea, 448 treatment of, 76 of ureter, 637 of urethra, 687 . Typhoid bacillus, acute osteomyelitis and, 741 fever, ulcers of skin and, 230 osteomyelitis, 749 perforation, ulcers of intestine and, 831 544 Ulceration of bone, 753 Ulcerative arthritis, 782 syphilides, 64 Ulcers, duodenal, 520, 525 of intestine, 544 of rectum, 728 actinomycotic, 729 chancroidal, 728 non-specific, 728 simple, 728 syphilitic, 728 tuberculous, 728 rodent, 93 of skin, 229 . , of stomach, 521. See Gastric ulcer, venereal, mixed, 690 simple, 689 Ulna, dislocations of, 890 Ulnar arterv, ligation of, 273 bursa, extension of infection trom. 221 Umbilical fistula?, congenital, 50 1 hernia, 934 congenital, 934 infantile, 935 Upper extremitv, bones of, fractures ot, 826 of femur, fractures of, 8o2 of humerus, fractures of, 831 of radius, fractures of, 841 Uranoplasty, 419 1026 INDEX Uremia, 121 Cheyne-Stokes respiration in, 122 convulsions in, 122 shock and, 104 symptoms of, 121 treatment of, 122 Ureter, cysts of, 637 diseases of, 632 epithelioma of, 637 implantation of, into bladder, 645 inflammation of, 633 injuries of, 632 obstruction of, 633 symptoms of, 633 treatment of, 634 operations on, 638 papilloma of, 637 prolapse of, 632 sarcoma of, 637 tumors of, 637 prognosis of, 638 symptoms of, 638 treatment of, 638 wounds of, 632 symptoms of, 632 treatment of, 632 Ureteral calculus, 635 cystoscopy in, 635 prognosis of, 636 symptoms of, 635 treatment of, 636 x-rays in, 635 Ureterectomy, 643 Ureteritis, 633 symptoms of, 633 treatment of, 633 Ureterotomy, 643 in renal calculus, 627 Uretero-ureterostomy, 645 Urethra, congenital absence of, 672 contusions of, 674 cysts of, 687 diseases of, 676 epithelioma of, 687 treatment of, 687 foreign bodies in, 687 fungoid pedunculated polyp of, 687 inflammation of, 676 injuries of, 674 malformations of, 672 papilloma of, 687 rupture of, 674 symptoms of, 674 treatment of, 675 stricture of, 680 diagnosis of, 682 internal urethrotomy in, 686 organic, 680 spasmodic, 680 symptoms of, 681 treatment of, 682 urine in, 681 tumors of, 687 wounds of, 674 Urethral calculus, 687 Urethritis, acute, 676 diagnosis of, 677 prognosis of, 677 symptoms of, 676 treatment of, 677 posterior, 676 Urethroscope, electric, 679 Urethrotome, Otis-Wyeth, 686 Uric acid calculi, 657 Urine in cholelithiasis, 578 in cystitis, 651 hi delirium tremens, 115 examination of, 638 cryoscopy in, 638 indigo-carmine test in, 639 phenolsulphonephthalein test in, 638 phloridzin test in, 638 in fat-embolism, 111 incontinence of, 671 nocturnal, in children, 670 retention of, 670 in senile hypertrophy of prostate gland, 712 in stricture of urethra, 681 in tuberculosis of kidney, 619 in tumors of bladder, 665 of kidney, 628 in vesical calculus, 659 Valentine irrigating apparatus, 678 Varicocele, 693 diagnosis of, 694 symptoms of, 694 treatment of, 694 Varicose aneurism, 251 veins, 261 Varix, saphenous, diagnosis of, from femoral hernia, 932 Veins, angioma of, 267 diseases of, 260 inflammation of, 260. See Phlebitis, injuries of, 260 varicose, 261 atrophy of skin in, 264 diagnosis of, 265 of leg, 261 ring enucleator in, 266 symptoms of, 264 treatment of, 265 Trendelenburg's sign in, 264 Velpeau bandage, modified, 137 Venereal ulcers, mixed, 690 simple, 689 Venous anesthesia, 171 hemorrhage, 123 Ventral hernia, 938 appendicitis and, 569 Vertebral artery, ligation of, 272 bodies, tuberculosis of, 788 INDEX 1027 Vesical calculus, 657 cystitis in, 658 diagnosis of, 059 in female, 664 hematuria in, 658 lateral lithotomy in, 663 litholapaxy in, 6(50 operation for, 660 choice of, 664 pyuria in, 659 suprapubic lithotomy in, 661 symptoms of, 658 treatment of, 660 urine in, 659 varieties of, 657 x-rays in, 659 Vesicular mole, 95 Villous arthritis, 782 papilloma, 87 tumors of bladder, 665 Virginal hypertrophy of breast, diffuse, 487 Visuopsychic area of brain, 347 Visuosensory area of brain, 347 Volkmann's contracture in fractures, 810 Volvulus, intestinal obstruction and, 541 von Graef's sign in exophthalmic goitre, 406 von Langenbeck's operation for removal of floor of mouth, 438 of tongue, 438 of tonsil, 438 V-shaped fractures, 806 W Warts, 86 of penis, 692 of scrotum, 692 of skin, 235 tuberculous, 231 Wassermann reaction in acquired syphilis, 65 in syphilis of epididymis, 703 of testicle, 703 Watson's lumbar drainage apparatus, 670 Weak foot, 976 Webbed fingers, 980 Wens, 97 Wet dressings, 144 Whale-bone sound with adjustable ivory tips, 443 Whitehead's operation for prolapse of rectum, 739 Whitman's brace for flat-foot, 978 method of reduction of fracture of upper extremity of femur, 855 splint in tuberculosis of hip, 795, 796 Wilson's empyema drainage tube, 466 Wolfe's methods of skin-grafting, 240 Wool-sorter's disease, 47 Wounds of abdomen, 504 Wounds of bladder, 6 17 of bloodvessels, 248 of chest-wall, 460 closure of, 145 of heart, 245 dressings for, 143 of face, 387 of joints, 768 of kidney, 605 of larynx, 388 of muscles, 295 of neck, 387 of nerve trunks, 303 of penis, 688 of pericardium, 241 of rectum, 723 of scalp, 328 of scrotum, 688 of tendons, 295 of testicle, 700 of trachea, 388 of ureter, 632 of urethra, 674 Wrist, amputation at, 954 dislocations of, 892 tuberculosis of, 800 symptoms of, 800 treatment of, 800 Wrist-joint, fractures in vicinity of, 843 traumatic arthritis in, 772 tuberculous arthritis of, 800 Wyeth method of amputation at hip- joint, 957 Xanthine calculi, 658 X-ray dermatitis of skin, 193 X-rays in acute osteomyelitis, 745 in carcinoma of breast, 499 of stomach, 532 in chronic arthritis, 780, 781 in diagnosis of fractures, 809 in hydronephrosis, 635 in renal calculus, 627 in sarcoma of bone, 761 in seminal vesiculitis, 707 in subparietal injuries of kidney, 604 in tuberculosis of bone, 751 in ureteral calculus, 635 in vesical calculus, 659 Yaws, 228 Young's radical operation for carcinoma of prostate, 721 Zygoma, fractures of, 821 COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED _ — ^ J~~ C28I23B1M100 DATE DUE DATE BORROWED V » - ^ JAN 6 1943 ^pAu- IfejU^^